How much does a liter of donor human milk cost? Cost analysis of operating a human milk bank in Italy

This study was a cross-sectional study performed at “Bambino Gesù” Children’s Hospital, Rome, Italy in 2019. The activity-based costing (ABC) method usually used for estimating the costs of blood banks was used to estimate the one-year operational costs and the per liter unit costs at our HMB [22].

This study does not contain any studies with human participants performed by any of the authors. For this type of study informed consent is not required.

For reporting our modelling study, we followed the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Statement [23].

The “Bambino Gesù” Children’s Hospital HMB was established in 1989 and is the sole Human milk Bank in Rome and in the whole area of Lazio, connected to NICUs and part of the Italian Association of Donor Human Milk Banks. We follow and sustain breastfeeding specific advice providing support to mothers who are breastfeeding or who must maintain milk production during their baby’s stay in the NICU [24]. The production process was developed based on “Italian National Recommendations for the Organisation and Management of Human Milk Banks as a Tool for the Protection, Promotion, and Support of Breastfeeding”.

[10, 25]. DHM is pasteurized utilizing the Holder pasteurization method (62.5 °C for 30 minutes) before use, to eliminate most bacterial pathogens and viral transmission [26]. As indicated by the Italian guidelines, the use of the Hazard Analysis and Critical Control Points (HACCP) is strongly suggested [27].

Processed DHM is provided in hospitals to preterm and low birth weight infants, children with congenital heart disease, and high-risk surgical infants, according to the provider’s prescription.

Donors for our HMB are mothers whose babies are admitted to our hospital, and nursing mothers who have seen recruitment information. They are carefully selected within 12 months of lactation if they are in good general health (the most important points are not smoking, not drinking, no recreational or other drugs) and have then tested negative for Human Immunodeficiency Virus, Hepatitis B, Hepatitis C, and syphilis. In addition, a bacteriological count is carried out on a small aliquot of breast milk once per human donation, and then randomly during the donation period [28]. Donors receive no monetary compensation for the donation. They obtain milk by mechanical pump or by manual extraction for a total period of 3 months. The milk is collected in disposable containers of polypropylene and stored in the freezer compartment of the donor’s home refrigerator before delivery to the HMB. A driver from our hospital, collects the milk from donors’ homes 3 hours / day 5 days / week, using a car donated to our bank by the biggest dairy cow farm in Rome. It is important that the cold chain is never interrupted. Therefore, the milk is collected at the lactating mother’s home from her freezer; it is transported to the car in a refrigerated bag and transported by car inside a freezer that maintains the temperature at − 20 °C. Once in the hospital, the milk is brought to the HMB in a cooler bag.

The milk thus collected is then stored in a freezer at − 24 °C in the Lactarium Room. Inside the Lactarium, health workers prepare all the nutritional products of the hospital and, in particular, pasteurize the milk donated.

In our study, all DHM donations and consumptions are expressed in the international unit of a liter. All costs used in the ABC program are expressed in euros (€).

To facilitate calculation, we excluded costs incurred by donors using their mechanical pump and storage in their home freezer compartment, and we included only certified data collected from budgets, financial and expenditure reports of “Bambino Gesù” Children’s Hospital HMB in 2019.

We calculated direct and indirect costs of collection and management of a liter of milk to our bank’s DHM:

The general costs, the staff costs and the depreciation of infrastructure allocation basis was the percentage of HMB’s personnel costs compared to the hospital’s total cost of personnel (0.04%).

Then we allocated the assigned indirect costs down to each collected liter. For the sole doctor who worked not only in the HMB but also in the Neonatal Intensive Care Unit, charges were calculated according to the working hours spent at each cost center. In order to assess direct costs of collection and transport of milk, we analysed the driver’s compensation, insurance, tires, and gasoline costs.

We estimated also direct and indirect costs of the Lactarium, analysing every single cost for the preparation and pasteurization of bottles of DHM, and then for the room cleaning.

We also evaluated the charges for liters of our DHM delivered to four other hospitals in Rome.

The total cost of each type of direct cost during 2019 was divided by the number of the annual total donated liters, in order to have the cost / liter value. In Table 2 we report direct costs for collection and management of a liter of our bank’s DHM (including microbiological testing procedures on milk before pasteurization). Among these, the total cost of salaries of medical and paramedical staff (€ 21,101.00 and € 40,798.00 respectively) and transport (€ 18,955.00) was fixed.

In Table 3 we describe the prices of medical consumables for collection and management of a liter of DHM. Even if expensive, the costs related to transporting DHM are not the highest among those that determine the charge of DHM, after the costs for medical and paramedical staff have been accounted for (Table 4): while the sole doctor works mainly in NICU (only 0.15 full-time equivalent (FTE) in the HMB), paramedical staff members involved in milk processing work full time in HMB (1.0 FTE).

Direct and indirect costs of the Lactarium Room are reported in Table 5. Costs of consumables per 250 mL single-use feeding bottle are available in Table 6 and were negligible (about € 1.00 per 250 mL single-use feeding bottle). The time spent on different activities was used to assess costs (reported in Table 7: about 6 minutes for each bottle).

Starting in May 2019, our bank also started supplying DHM for free to other hospitals in our city, for a total cost of € 44,435.00: each charge is reported in Table 8.