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JOGNN RESEARCH

Peer-to-Peer Milk Donors’ and


Recipients’ Experiences and
Perceptions of Donor Milk Banks
Karleen D. Gribble

Correspondence ABSTRACT
Karleen D Gribble,
Objective: To explore the intersection of peer-to-peer milk sharing and donor milk banks.
BRurSc, PhD, School of
Nursing and Midwifery, Methods: A descriptive survey design containing closed and open-ended questions was used to examine women’s
University of Western perceptions of peer-to-peer milk sharing and milk banking. Closed-ended questions were analyzed using descriptive
Sydney, Locked Bag 1797,
statistics and conventional qualitative content analysis was used to analyze open-ended responses.
Penrith NSW 2751,
Australia. Setting: Participants were recruited via the Facebook sites of two online milk-sharing networks (Human Milk 4 Human
karleeng@uws.edu.au Babies and Eats on Feet).

Keywords Participants: Ninety-eight milk donors and 41 milk recipients who had donated or received breast milk in an arrangement
milk banking that was facilitated via the Internet.
wet nursing
milk sharing Results: One half of donor recipients could not donate to a milk bank because there were no banks local to them or they
social media did not qualify as donors. Other respondents did not donate to a milk bank because they viewed the process as difficult,
had philosophical objections to milk banking, or had a philosophical attraction to peer sharing. Most donor respondents
felt it was important to know the circumstances of their milk recipients. No recipient respondents had obtained milk from
a milk bank; it was recognized that they would not qualify for banked milk or that banked milk was cost prohibitive.
Conclusion: Peer-to-peer milk donors and recipients may differ from milk bank donors and recipients in significant
ways. Cooperation between milk banks and peer sharing networks could benefit both groups.
JOGNN, 42, 451-461; 2013. DOI: 10.1111/1552-6909.12220
Accepted March 2013

uman milk banks collect and process dona- is usually also pasteurized (Hartmann, Pang, Keil,
Karleen D. Gribble,
BRurSc, PhD, is an adjunct
H tions of expressed breast milk and provide
the milk to infants in need of human milk through
Hartmann, & Simmer, 2007). The screening crite-
ria as well as the processes involved in produc-
fellow in the School of
Nursing and Midwifery, the health system. The first milk banks opened ing banked milk make it a scarce and costly re-
University of Western early in the 20th century, however, when HIV was source (Simmer & Hartmann, 2009; Woo & Spatz).
Sydney, Penrith, Australia. found in the milk of infected women in the 1980s, The costs of banked donor milk are borne by the
many milk banks were closed (Jones, 2003). With health system, insurance companies, or individu-
implementation of rigorous screening, testing, and als. In the United States, banked donor milk can
pasteurization, the number of milk banks has since cost families as much as $4.50 per ounce (Woo &
increased to hundreds worldwide (Azema & Calla- Spatz). Banked donor milk is generally only avail-
han, 2003; Grøvslien & Grønn, 2009; Omarsdot- able through prescription by a doctor. Globally,
tir, Casper, Akerman, Polberger, & Vanpee, 2008; the vast majority of banked donor milk is given to
Pimenteira Thomaz et al., 2008). critically ill or premature infants in neonatal inten-
sive care units (NICUs) (Simmer & Hartmann; Tully,
Milk bank donors must meet criteria relating to Lockhart-Borman, & Updegrove, 2004) where the
their health, consumption of pharmaceutical or deprivation of human milk can lead to serious
alternative medicines, alcohol or smoking, age complications such as necrotizing enterocolitis
of their children, history of international travel or (Quigley, Henderson, Anthony, & McGuire, 2007).
country of residence, and ability to donate a min-
The author reports no con- imum quantity of milk (Woo & Spatz, 2007). Do- Since the introduction of home refrigeration, moth-
flict of interest or relevant nated milk undergoes bacteriological testing and ers have been able to easily share expressed
financial relationships.

http://jognn.awhonn.org 
C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 451
RESEARCH Milk Donors’ and Recipients’ Experiences and Perceptions of Donor Milk Banks

ceptions of the women involved in Internet-based


The cost imposed by some banks on recipient parents is a peer-to-peer milk sharing.
strong disincentive to some women for donating milk to a
milk bank.
Methods
A descriptive survey design containing closed
and open-ended questions was used to examine
breast milk directly with one another outside of women’s perceptions of peer-to-peer milk sharing
any organization or system. Until very recently, and milk banking. A convenience sample of peer-
such peer-to-peer milk sharing required that moth- to-peer milk donors and recipients was recruited
ers in need of milk be personally acquainted with via advertisement on the Facebook pages of the
mothers prepared to share milk. For this rea- two largest milk-sharing groups, Human Milk 4 Hu-
son, peer-to-peer milk sharing occurred sporad- man babies and Eats on Feets. By its very nature,
ically and on a small scale and has been the peer-to-peer milk sharing is highly decentralized,
subject of only scant research (Bar-Yam, 2005; and no records are kept of who is sharing milk with
Thorley, 2009). whom. As such, obtaining a representative sam-
ple of this group was impossible. However, wide
More recently, social networking via the Internet advertisement of the study aimed to garner as di-
has been used to connect mothers requiring milk verse a sample as possible.
with those willing to donate human milk. There are
currently more than 170 such Facebook groups To be eligible to participate, individuals were re-
across more than 50 countries. This use of so- quired to have donated or received breast milk in
cial networking means that milk sharing can easily the previous six months in an arrangement that
occur between individuals previously unknown to was facilitated via the Internet and also to be
one another and on a large scale. proficient reading and writing in English. Adver-
tisements for the study directed individuals who
Some health authorities have been alarmed by met the inclusion criteria and who were interested
the phenomenon of direct milk sharing and have in participating, to e-mail the study author indi-
warned parents to avoid peer-to-peer milk shar- cating their desire for further information. In re-
ing. These authorities have expressed concern sponse, individuals were e-mailed a letter outlin-
that the potential for disease transmission or ing the method, background, and purpose of the
contamination of the milk is unacceptably high study. In this letter those who wished to participate
(Agence Francaise de Securite Sanitaire des Pro- were instructed to request via e-mail a copy of
duits de Sante; 2011; Health Canada, 2010; U.S. the study questionnaire; the request of which was
Food and Drug Administration; 2010). Parents in considered as providing informed consent. In re-
need of milk are advised instead to seek human sponse to this request, individuals were e-mailed
milk only from a milk bank. a copy of the relevant study questionnaire. Ninety-
one percent of peer milk donors and 87% of peer
However, in some regions milk banks have re- milk recipients who requested the study question-
ported milk shortages. These shortages have naire completed and returned the questionnaire.
been blamed on the advent of peer-to-peer milk- Approval for the study was obtained from the Uni-
sharing networks. It has been suggested that versity of Western Sydney Human Research Ethics
women are donating milk to their peers in pref- Committee.
erence to milk banks, decreasing the volume of
banked donor milk available to milk banks and Peer-to-peer milk donors and recipients were
therefore to NICUs (Dutton, 2011; Newman, 2011; asked questions relating to their interactions with
Rochman, 2011). Thus, peer-to-peer milk sharing milk banks as shown in Table 1. Closed-ended
has been represented as depriving sick infants questions were analyzed using descriptive
of milk that might be necessary for their survival statistics and conventional qualitative content
(Newman). analysis was used to analyze open-ended re-
sponses (Hsieh & Shannon, 2005). Questionnaire
As a part of a larger study examining Internet- responses were read, reread, and initially coded
facilitated peer-to-peer milk sharing, women’s rea- to identify recurring categories of response.
sons for donating milk to, or receiving milk from, a Categories that were conceptually similar were
peer rather than a milk bank were explored. This is combined, as appropriate. The number of re-
the first study to consider the experiences and per- sponses within each category were counted and

452 JOGNN, 42, 451-461; 2013. DOI: 10.1111/1552-6909.12220 http://jognn.awhonn.org


Gribble, K. D. RESEARCH

Donor respondents offered a variety of reasons


Table 1: Study Questions for Milk Donors for not donating to a milk bank. Many donors ex-
and Recipients pressed that they lacked opportunity to donate to
a milk bank because there was no local milk bank
Milk donors
or they did not meet milk bank criteria: “There is
Have you previously donated milk to a human milk bank? no milk bank in New Zealand,” and ‘Due to the
If yes, where did you donate and why did you not donate to fact that I was on medications (although safe for
the milk bank in preference to donating direct to another breastfeeding) they would not accept my milk.”
mother?
Many donor respondents also expressed a view
If no, why not?
that the process of donating to a bank was difficult
How important to you is knowing the circumstances of the and that this had dissuaded them from donating to
need of your milk recipients for breast milk to your a milk bank: “I didn’t want to deal with the hassle
motivation to provide milk? of packing/shipping or taking milk to a milk bank.
Milk Recipients Also, I didn’t want to have to get blood tests each
time like I’ve read many milk banks ask you to.
Had you tried any alternatives to internet-facilitated
It’s time consuming,” and “I would have had to
peer-to-peer donor milk before you obtained donor milk
pump at least 300oz within one month to qualify
(e.g., increasing your own milk supply, obtaining milk
to donate.”
from a human milk bank, obtaining donor milk from a
friend or relative, using infant formula)? Some donor respondents explained that a philo-
If yes, please describe what you had tried and why this sophical objection to milk banking had influenced
was not sufficient or why you decided not to continue? their decisions to donate to a peer: “I prefer to do-
nate directly to the mother because I know exactly
where my milk goes, I know it won’t be pasteur-
ized and I know it’s free of charge to the mother in
responses organized by frequency. The reliability need.” In addition:
and trustworthiness of the coding was tested by
providing a description of the coding categories All the tests, rules, and how they treated my
and a random 20% sample of the responses to milk put me off. I hated the idea of sending
each question to two coders. The percentage of my milk somewhere and have it treated like
agreement between these coders was 98%. a specimen instead of the life force it is. I
hated not knowing where my milk was go-
ing. I also hated the idea of my milk being
Results sold to another family when it didn’t need
Ninety-seven milk donors and 41 milk recipients to be.
from North America, Europe, Oceania, and Asia
participated in the study. Donors ranged in age Finally, some donors described a philosophical at-
from 21 to 43, had from one to four children and traction to aspects of peer-to-peer milk sharing
previous breastfeeding experience from 4 to 120 that contributed to their decision to give their milk
months. The child of the most recent lactation directly to another mother rather than to a milk
ranged in age from 0 to 17 months, and donors bank: “I chose [Eats on Feets] this time because
had from one to nine recipients. Recipients ranged of the issue of access for mother who would not
in age from 21 to 45, had from one to five children qualify for milk bank milk and also the personal
and previous breastfeeding experience of 0 to 118 aspect of milk sharing this way.” A summary of
months. The age of the recipient child at the time the reasons why donor respondents donated to
of first donation ranged from 1 day to 11 months. a peer rather than to a milk bank is presented in
Recipients had from 1 to 40 donors from whom Table 3.
they had received 1.2 L to 300 L. Characteristics
of participants are summarized in Table 2. Almost one half of the respondents (44 individu-
als) did not donate to a milk bank because it was
A total of six donor respondents had previously not possible for them to do so due to their loca-
donated to a milk bank, four to a not-for-profit milk tion or because milk bank criteria excluded them.
bank and two to a for-profit milk bank. The remain- The publicity about shortages of banked milk af-
ing 88 donor respondents had never donated to a fected one donor respondent who decided that
bank. she would make future donations via a milk bank:

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RESEARCH Milk Donors’ and Recipients’ Experiences and Perceptions of Donor Milk Banks

Table 2: Characteristics of Study Participants

Mean Standard deviation

Donors

Age 30 yrs (n = 97) 4.2

Number of children 1.7 (n = 97) 0.82

Age of child of most recent lactation 3.2 mo (n = 93) 3.5

Duration of previous breastfeeding experience 21 mo (n = 93) 18.0

Number of recipients 2.1 (n = 97) 1.7

Volume of milk donated 26 L (n = 88) 39.4

Recipients

Age 30 yrs (n = 41) 6.5

Number of children 2.0 (n = 41) 1.1

Age of recipient child 3.3 mo (n = 41) 3.4

Duration of previous breastfeeding experience 17 mo (n = 41) 21.6

Number of donors 8.1 (n = 41) 7.8

Volume of milk received 68 L (n = 34) 75.4

After hearing about the Mother’s Milk Bank mothers went through trying to breastfeed their ba-
in Austin making an urgent call for donations bies is a huge motivation. Any hassle of express-
. . . it has swayed my personal thoughts. . . . ing and storing my milk is NOTHING compared to
I recently decided to make any future what these mother faced.” In addition,
donations to the Milk Bank. While every
baby should have opportunity to be fed Pumping milk, while not difficult, is time-
breast milk, I believe it’s more important for consuming. Especially since I only pump to
those babies who are born sick. donate. . . . Knowing that she needs the milk
for her little guy and being able to see him
In contrast to milk bank donors, peer-to-peer milk
grow and thrive through pictures keepings
donors generally know the circumstances of their
me motivated to keep my supply up (and
recipients. This feature of peer-to-peer milk shar-
not just level out to just what my daughter
ing was important to many donor respondents.
needs).
Fifty-seven donor respondents said that it was im-
portant or very important that they know the cir-
Some donor respondents gained a sense of sat-
cumstances of their recipients, 16 said that it was
isfaction or were gratified by knowing that their
somewhat important, and 23 said that it was not
milk could help a child: “It’s gratifying to hear a
important. The most common reason for wanting
story of a child in need and know that I am able to
to know about their recipient’s situation was to
help.”
evaluate whether the need for milk was genuine
It was clear that donor respondents valued their
Some donor respondents wanted to know their re-
milk highly: “I think it was very important to know
cipient’s situation to make a judgment of their wor-
why that mother needed milk. I feel like I was giv-
thiness as a recipient of their milk: “I like to know
ing a part of myself away, so I wanted it to go to
that there is a genuine need. I wouldn’t donate to
someone who truly needed it,” and “I did want to
someone who is too lazy to pump, or someone
know the circumstances so that I was sure it was
who was uninterested in breastfeeding herself.”
not going to be wasted or sold on.”
And others wanted to ensure that their recipient
Donor respondents also commonly indicated that was the most needy:
knowledge of their recipients’ situations provided
them with the motivation that they required to I would much rather donate to a child who
express milk: “Knowing the struggles that these will benefit and needs the milk the most (a

454 JOGNN, 42, 451-461; 2013. DOI: 10.1111/1552-6909.12220 http://jognn.awhonn.org


Gribble, K. D. RESEARCH

Table 3: Reasons Why Donors Had not Donated Their Milk to a Human Milk Bank

Category of response Subcategory F Example of response


Lack of opportunity No local milk 29 “There is no milk bank around I could donate to (I
tried every place I could think of to donate the 40
litres of breastmilk that my son couldn’t drink due
to severe allergies–it had to be thrown out L).”

Did not qualify 9 “I’m not permitted to donate to U.S. milk banks as I
lived in the UK and I’m considered a risk for
transmitting mad cow disease.”

Milk bank not accepting more 3 “I had enquired into donating to a milk bank and was
donors told that they were not taking any more donations
due to financial reasons.”

Was not prescreened 2 “[I had milk in my freezer to donate but] I was told I
would have needed to be prescreened before I
started pumping.”

Milk bank did not respond 1 “I wanted to donate milk to a milk bank and attempted
to contact the one closest to me but never got a
response.”

Milk banking is difficult Viewed the process of 11 “The process is long and tiring. My milk can go to
donating as a barrier local mothers much easier.”

Don’t know about milk banks 7 “There is not very much information easily accessible
about human milk banks.”

Didn’t want to ship milk 4 “I didn’t want to deal with the hassle of
packing/shipping.”

Philosophical Object to parents having to 27 “I would not donate to a milk bank because I don’t
objections to milk pay for banked milk support the way they charge exorbitant amounts
banking of money to families who are obviously in need.”

Do not like milk to be 5 “I like that my milk isn’t fully processed when I share it
pasteurized with the family I donate to- all the good antibodies
and cellular components etc are retained and
able to be used instead of lost in the “cleaning”
process that milk bank milk undergoes. I know
they need to do that, but to me it feels like my milk
is being used more fully when shared fresh.”

Local milk banks are for profit 2 “I have a fundamental aversion to charging parents
exorbitant amounts of money to provide for the
health of their children . . . I noticed that the milk
bank collected milk, then gave it to a for profit
company which processed the milk and sold it to
hospitals and families.”

Philosophically Prefer to know recipient 10 “I think that would be too impersonal for me. I like
attracted to peer knowing who is getting my breastmilk.”
sharing

Wanted to help mothers and 4 “I chose EoF over milk bank this time because of the
children who would not issue of access for mothers who would not qualify
qualify for banked milk for milk bank milk.”

JOGNN 2013; Vol. 42, Issue 4 455


RESEARCH Milk Donors’ and Recipients’ Experiences and Perceptions of Donor Milk Banks

ments, because of their locations, or because of


Knowing why milk was needed provided donors with motivation the cost. Recipient respondents made statements
for the work of expressing. such as, “I had to use formula because I didn’t
make enough milk and the banks said they could
not sell me any milk,” and “I contacted the one and
premature child or a child with disabilities or only milk bank in Canada but was not able to ob-
intolerance of formula or a mother who ab- tain milk from them for various reasons (location,
solutely can’t breastfeed) rather than a child lack of supply, cost).”
who would be fine with formula or whole
milk. Nine respondents rejected attempting to obtain
banked milk because it was inaccessible or be-
Table 4 presents a summary of the rea- cause of the cost: “I knew that we could not afford
sons why donor respondents felt it was impor- milk banks as I had looked into this with my pre-
tant to understand the circumstances of their emie [previous child] and at $4/oz that was way
recipients. beyond what we could afford,” and “There is no
local milk bank in our area.” One respondent, a
None of the recipient respondents had used Malaysian Muslim woman, explained that that she
banked milk. Three recipient respondents had must know her donors to determine that they were
tried to obtain banked milk but were unsuccessful also Muslim and to take account of the relation-
because their children did not meet the require- ship created by the sharing of milk. A summary of

Table 4: Reasons Why Donors Felt It Was Important to Know the Circumstances of the Milk
Recipients

Category of response F Example of response


Needing to know that the need for 16 “It is very important to me to make sure the milk that I have expressed will be
breast milk was real used to provide nutrients for a baby in need.”

Knowing is a motivator donate or to 13 “It is a sacrifice and if I know the situation it is motivational for me to sit with
continue to express milk pumps attached to me multiple times a day.”

Would not be happy to donate if 6 “I am not just going to give the milk to just anybody. I want to know that the
mother has not worked to mom is having a lot of difficulty producing her own milk or is physically
maximize her own milk supply unable to produce her own. A mom that just seems to have gotten lazy
with pumping or is not putting forth effort to increase her supply for her
child will probably not receive milk from me.”

Like to know the story 5 “I like to know why they need the milk, but only because I’m curious.”

Donating milk is something personal 5 “As I have literally put a piece of myself into these bottles and bags, I want to
feel at peace that I am giving my milk to someone who needs it.”

So I can choose the recipient that will 4 “I would much rather donate to a child who will benefit and needs the milk
benefit most the most.”

Knowing is fulfilling 3 “Knowing that I am helping her to provide her baby with what she can’t
provide herself is really fulfilling and makes me want to give her all the
milk I can.”

No reason provided 3

So the relationship is open 2 “So there is an open and honest relationship.”

Match the age of the baby 2 “What is important to be is that the child I donate to is around the same age
as my current nursling.” D83

To know that the milk is valued 1 “I don’t want my milk that I spent hours expressing, lovingly for my baby, to
go to someone who won’t treasure it.”

To have empathy 1 “I would want to know in order to justify my donation, to put myself in that
mother’s shoes . . . to understand her need.”

456 JOGNN, 42, 451-461; 2013. DOI: 10.1111/1552-6909.12220 http://jognn.awhonn.org


Gribble, K. D. RESEARCH

Table 5: Reasons Why Recipients Did not Use Banked Donor Milk

Category of response f Example of response


Failed to obtain donor milk 3 “I contacted a milk bank, but they stopped responding to me after my
first email. My daughter does not have a ‘medical need.’”

Rejected attempting to obtain donor milk 9 “I had looked into obtaining milk from a human milk bank . . . but it
seemed to be only available for preterm or sick babies and even
if I could obtain it, it was very expensive.”

Banked milk was not acceptable/too 1 “The mothers must be Muslim and is breastfeeding their children as
risky/recipient must know donor well . . . frequent visit to the milk donor is important to keep track
on their location.”

reasons why recipients had not used banked milk on the willingness of potential donors to donate a
is presented in Table 5. milk bank deserves further investigation.

The processes involved in donating to a milk bank


Discussion were considered to be a barrier by many peer
Only a Portion of Lactating Women donor respondents who had already spent a con-
Are Potential Milk Bank Donors siderable amount of time expressing milk for dona-
Donors in this study were sharing their milk di- tion. Thus, simplification of the donation process,
rectly with other mothers, and few had had any for example, local collection depots rather than in-
interaction with a human milk bank. One half of dividual shipping of milk, could make more milk
the donor respondents were excluded from do- available to milk banks.
nating to a milk bank because they did not qualify
or because there was no local milk bank. This sug-
Providing Information as Motivation
gests that not all lactating women can be viewed
for Donors
as potential bank donors. The reasons given by
Many donor respondents stated that they would
the remaining donor respondents for failing to do-
not donate to a milk bank because they preferred
nate to a bank suggest modification of the milk
to know the recipient. More than one half stated
banking process that may assist in bank donor
that it was important or very important for them to
recruitment.
know why their recipient(s) needed milk. The rea-
sons donor respondents wanted know the circum-
Reducing the Cost and Process stances surrounding the need for donor milk were
Disincentive to Milk Donation primarily related to ensuring that the need was
Although almost all milk banks are not-for-profit genuine or understanding the situation so as to be
organizations, the cost imposed by banks on re- motivated to provide milk. Obtaining milk from a
cipient parents in some jurisdictions (e.g., North milk bank requires physician assessment of infant
America) can be a strong disincentive to women need and so deals with the concern of donors who
donating milk to a milk bank. Donor respondents simply required that their milk be given to a needy
were affronted by the idea that milk banks could infant.
charge milk recipients a great deal of money for
their gift of milk. Educating potential donors about This may not be sufficient for donor respondents
the costs of processing banked milk might alle- who wished to assess whether recipients had
viate some of these concerns. In addition, fund- “tried hard enough” to supply their own milk to
raising to cover the expenses of recipients who their infants. This sentiment, implies an unwilling-
cannot have the cost of banked milk borne by ness to do someone else’s “breastwork” (Bartlett,
their hospital or health insurance might address 2005; Stearns, 2009) if she is capable of doing it
this issue. Finally, milk banks could provide infor- herself. It is also a judgment of the mother’s worthi-
mation on the proportion of their recipients who ness, responsibility, or goodness (Murphy, 2000).
have their costs covered by their hospital or insur- Further, some donor responses indicated that they
ance so that potential donors can be reassured placed a high value on their milk and wished to
that few recipients are paying directly for milk. The ensure that the recipient(s) would appreciate the
impact of the costs involved in using banked milk worth of the milk. The value that donors place in

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RESEARCH Milk Donors’ and Recipients’ Experiences and Perceptions of Donor Milk Banks

their milk may partially flow from the idea that the required of them is large. No payment is made for
milk is a part of the donor’s self (a concept specif- donated milk but the milk is donated with a cost
ically identified by some donors), and so the gift to donor and their families; breast milk can only
of breast milk may be perceived as a gift of the be considered to be free if the value of women’s
self. These concerns are unlikely to be able to be labor is ignored (Shaw, 2010). Although none of
addressed by milk banks. the donor respondents desired payment for their
work or milk, there is the sense that information
The absence of feedback to donors about the about their recipient’s need for their milk consti-
need for and outcome of banked donor milk is tutes a reward for their work that facilitates milk
a barrier to donation that could be overcome. Pre- donation.
vious research has found that milk bank donors
would like to know more about what happens to Thus, providing milk bank donors with greater in-
their milk after donation including who receives the formation could make more banked donor milk
milk, why the milk is needed, and why the infant’s available by providing donors with motivation to
mother is unable to provide milk (De Alencar & donate milk. This would increase the number of
Seidl, 2010). Milk banks have historically followed women able to donate and/or increase the length
organ donation policy in maintaining anonymity of time for which donors continue to donate. In-
and not providing donors with information about formation may also be considered a type of reci-
how their milk is used. Anonymity in organ do- procity that acknowledges the effort and giving
nations exists because identification of recipients of self that is involved in milk donation (Shaw,
might result in feelings of obligation to continue 2010). Donors may not require identifying infor-
donations (Warwick, 1997). This constraint may mation to donate to milk banks but simply greater
not apply in milk donation because the milk of an- knowledge of the need for or the use of their
other can easily substitute for any individual donor. milk. As demonstrated by the donor respondent
Maintenance of anonymity also protects recipients who changed her mind about donating to a bank
from claims by donors, whether this is likely to be after hearing of shortages, even basic informa-
an issue in milk donation is unknown. However, tion demonstrating the need for milk can change
not all institution-facilitated milk banking preserves practice.
anonymity (e.g., Ghaly, 2012; Hsu et al., 2011) and
investigating how such models manage these is-
Referring Parents of Healthy Infants
sues is warranted.
to Milk Banks Is not Helpful
Recipient respondents had had very limited con-
There are logistical difficulties associated with pro-
tact with milk banks, and none of them had been
viding donors with information about the recipients
able to obtain banked donor milk. The infants of
of their milk. Many milk banks pool donations so
recipient respondents were generally healthy and
that recipients will receive milk from many donors.
without complex medical problems and so did
Furthermore, hospitals sometimes order milk from
not meet the criteria usually necessary to qual-
banks in anticipation of it being required so there
ify for banked donor milk. For the recipient re-
may be some time between donation and use.
spondents who were unable to provide their own
breast milk the choice of supplementary milk was
Some donor respondents reported that their abil-
infant formula or human milk donated by a peer.
ity to express milk was conditional upon knowing
Should these experiences be typical, statements
why it was needed because this provided encour-
by health authorities that those needing additional
agement that was necessary for them to be able
human milk for their infants obtain it from a milk
to express. In normal circumstances, the demand-
bank are not helpful at best and disingenuous at
and-supply principle of milk synthesis means that
worst. It does not assist families in need of milk
women are capable of producing milk far in ex-
for their children to be directed to milk banks that
cess of that required by their infants (Daly, Owens,
cannot supply them with milk, nor does it assist
& Hartmann, 1993; Kent et al., 2006). However,
milk banks to be inundated with requests for milk
motivation is required to engage in and sustain the
that they cannot supply.
work involved in milk expression. Milk expression
has been identified as demanding, tedious, and
stressful, requiring commitment and sacrifice over Identification of Milk Donors Provides
a protracted period (Avishai, 2007; Stearns, 2009). Safety to Islamic Milk Recipients
As such donors are not only donating their milk, One recipient respondent expressed a religious
but also their time and work and the investment imperative to know her donors. Although her view

458 JOGNN, 42, 451-461; 2013. DOI: 10.1111/1552-6909.12220 http://jognn.awhonn.org


Gribble, K. D. RESEARCH

was singular among the recipients in this study,


there is reason to believe that it may be an opinion Milk donated via peer sharing may be sourced largely from a
that is widespread in Muslim countries. Breast milk different pool of donors from that of milk banks.
has religious meaning in Islam with the infant hav-
ing a recognized right to breastfeed for two years
including via wet nursing (Shaikh & Ahmed, 2006).
However, the consumption of breast milk creates
a familial relationship (milk kinship) between the and Eats on Feets). Furthermore, the U.S. surgeon
woman and child and care must be taken to general’s appeal to make banked donor milk avail-
avoid consanguineous marriages (Parkes, 2001). able to more infants in NICUs, may have increased
Some Muslims consider that the feeding of banked the demand (U.S. Department of Health and Hu-
donor milk to hospitalized infants does not create man Services; 2011). Regardless of the reason,
a milk kinship relationship (Ghaly, 2012). However, the continuing growth in the need for banked
no Muslim country has a traditional milk bank (El- donor milk requires an increased supply of donors
Khuffash & Unger, 2012). Although traditional milk and their milk.
banking may be unacceptable to many Muslims,
changes in the process may make it permissible. Thus far, peer-to-peer milk-sharing networks ap-
The Duchess of Kent Hospital in Malaysia and pear to have been viewed as a threat to traditional
Adan Hospital in Kuwait provide a modified milk- milk banks as a competitor for the scarce resource
banking process in their NICUs whereby milk is of donors and their milk. The data from this study
not pooled and donor and recipient are introduced suggests a different possibility, that the milk being
to one another (Ghaly, 2012; Hsu et al., 2011). donated via peer-to-peer sharing is predominantly
This is effectively a regulated form of peer-to-peer sourced from a different pool of donors than that
milk sharing. The issue of milk kinship is another of milk banks. It seems that a large proportion of
reason for milk banks (especially those in areas women who donate to a peer are excluded from
with a large Muslim population) to consider allow- donating to a milk bank because of their location
ing for greater transparency in the milk banking or personal characteristics. Furthermore, it seems
process. that it is the very nature of peer sharing, where the
circumstances of recipients are known to donors,
that enables women to donate and the absence
Peer-to-Peer Donors and Recipients and of this information is a barrier to donation to a milk
Milk Bank Donors and Recipients Are bank. However, there is a possibility that some of
Recruited from Different Pools this latter group of donors might be able to be re-
Women have always shared milk with one another, cruited to milk banks with modification of the milk
but the scale of the online milk-sharing networks banking process. It is also possible that peer-to-
has led to fears that this new form of milk sharing peer milk sharing is decreasing the demand on
is jeopardizing the infants served by milk banks. milk banks from the population of relatively well
However, concerns about shortages of banked infants served by milk sharing.
milk have only been expressed in North Amer-
ica. Data on the amount of milk donated to milk The conclusions that can be drawn from this study
banks in North America is not available, but ac- are limited by the use of convenience sample of
cording to the Human Milk Banking Association of donors and though care was taken to recruit as
North America the amount of milk dispensed by diverse as sample as possible, it is unknown how
member milk banks has steadily increased from representative their views and experiences are of
1.2 million ounces in 2007 to 2.2 million ounces in the population of individuals involved in peer-to-
2011 (Personal communication, Jean Drulia, Pres- peer milk sharing. A further limitation of this study
ident Human Milk Banking Association of North was that it required respondents to be sufficiently
America, May 16, 2012). Thus, it seems that milk proficient in English to be able to complete the
shortages may be more a result of increased de- study questionnaire. This likely limited the partici-
mand rather than a decreased supply. Extensive pation of donors and recipients in countries where
publicity about peer-to-peer milk sharing includ- languages other than English predominate. Fur-
ing associated discussion about milk banks may ther research should be undertaken in languages
have increased awareness of banked milk and so other than English, in particular to explore milk
increased the demand for banked milk (the Fac- sharing in Islamic countries where, as noted, the
tiva database yielded 122 articles in print media belief in milk kinship impedes the development of
including the names Human Milk 4 Human Babies traditional milk banking.

JOGNN 2013; Vol. 42, Issue 4 459


RESEARCH Milk Donors’ and Recipients’ Experiences and Perceptions of Donor Milk Banks

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