Perception of donor breast milk and determinants of its acceptability among mothers in a developing community: a cross-sectional multi-center study in south-east Nigeria

Breastmilk has been well-established as the most optimal source of nutrient for infants particularly in the first six months of life [1]. This is partly because it contains bioactive substances that are essential to the development of the newborn’s immature immune system. This singular attribute of breastmilk makes it even more important for the preterm and/or low birthweight newborn whose weak immune system is vital for its survival. Apart from the immune system, other long-term benefits of the use of human breast milk in preterm is well documented. These include but not limited to decreased incidences of retinopathy and necrotizing enterocolitis of the newborn, better neuro-cognitive development and lower risk of development of childhood obesity and diabetes [2‐4]. It has been noted that newborns most susceptible to morbidity and mortality are those at greatest risk of not receiving the lifesaving benefits of breast milk [5].

Based on the benefits, the World Health Organization (WHO) recommends that all mothers should feed their infants solely with breast milk, exclusive of any other nutritional sources for the first six months of their infant’s life [6]. The recommendation further states that for infants who cannot receive breast milk from their own mothers, the next preferred option is donated human breastmilk. Donated breastmilk according to the National Institute of Health and Clinical Excellence (NICE) is breast milk expressed by a mother that is then processed by a donor milk bank for use by a recipient that is not the mother’s own baby [7]. The use of donor breastmilk over infant formulas in vulnerable newborns has been shown to significantly impact on neonatal mortality rates in countries around the world. In Brazil for instance, there has been a drastic reduction in neonatal mortality by a whopping 73% between 1990 and 2013, since it incorporated milk banks into its newborn health policy [8, 9]. Unfortunately, most developing countries with the highest burden of global neonatal mortality lag in the implementation of donor breastmilk as the best alternative for vulnerable infants.

In Nigeria, it is estimated that of the seven million children born every year only about 25% are exclusively breastfed from 0 to 6 months of age [10]. Sadly, this poor practice of breastfeeding has to a certain degree been implicated in the current high rate of neonatal morbidity and mortality in the country [10]. Even more worrying is the fact that there is currently no human breastmilk bank in the whole of the west Africa sub-region. Due to strong religious and cultural belief system, establishing human breastmilk bank in these settings for use in precarious situation where maternal milk is limited or not available such as prematurity, low birthweight or orphaned newborns requires an in-depth consideration of the acceptability of the concept by mothers in these settings. There is little discussion in local medical literature regarding the knowledge and willingness to use donor breastmilk among mothers in many developing communities. This study therefore sets out to assess the perception of the concept of donor breastmilk among mothers in several communities in south-east Nigeria. It further evaluated the factors that determine the willingness to participate in donation and/or use of donor breast milk among these mothers.

This cross-sectional multi-center study was conducted concurrently over a six months period between August 2016 to January 2017 in six different tertiary health facilities namely the University of Nigeria Teaching Hospital (UNTH), Enugu, Enugu State University Teaching Hospital (ESUTH), Enugu, Federal Teaching Hospital Abakiliki (FETHA) Ebonyi State, Federal Medical Centre Owerri, Imo State, Federal Medical Centre Umuahia, Abia State and Nnamdi Azikiwe University Teaching Hospital (NAUTH) Anambra State. Each of these hospital offers specialized medical services and serves as a referral center to primary, secondary and private health facilities from within and outside their respective state. These six tertiary health institutions are all located in the south-east area of Nigeria and were chosen out of the 10 tertiary institutions in the region using convenient sampling method. This was based on the presence of one or more authors of this work being a staff in the institutions and/or supervisor(s) of the data collection team. The study aimed to enroll two hundred and fifty mothers attending antenatal and postnatal clinics in each of the selected center using purposive sampling method. A structured pre-tested questionnaire was administered by self and/or interviewer-based supervision depending on the educational abilities of respondent.

This study reports a low knowledge of the concept donor breast milk and low awareness of policy regarding the use of Donor Breast Milk (DBM) in Nigeria but a relatively high willingness of mother to participate in the concept. This finding is similar to the results of a comparable survey on 198 mothers in a tertiary hospital in south-south Nigeria which showed that only 25.8% have heard about the concept of DBM but 59.1% strongly believed that human milk banking is necessary to assist orphaned and abandoned babies [13]. Another study that surveyed 448 mothers in Izmir, Turkey also showed that even though only 41.6% were aware of the concept of milk banking, 71.3% were willing to receive milk bank services and 68.8% were willing to donate their breastmilk [14]. Correspondingly, it was noted in our study that the most common source of information about donor breast milk was from healthcare workers which is identical to the 46.1% reported in another study in south-south Nigeria [13]. These is however contrarily to the finding of the study in Turkey where the media accounted for 85.7% of the information source of DBM among respondents. These differences may be related to the better availability of electronic media to mothers in Turkey where for instance 46% of women have access to internet and other electronic media compared to 28% in Nigeria [15, 16].

Like this study, the studies in Benin and Izmir showed a major concern about infection transmission was the common reason mothers were unwilling to accept donated breast milk for their babies [13, 14]. The authors of these studies specifically reported that 59.1% and 62.2% of surveyed mothers in Benin and Izmir respectively, were unwilling to receive donated breast milk stating the risk of contracting infections as a major concern. As noted in our study, the number of mothers who expressed unwillingness to use donor breast milk significantly reduced when they were assured that donor will be screened and tested for transmittable infections. This further strengthens the need for proper enlightenment of mothers and their families about the processes involved in the concept of human breast milk banking. In the same vein, our study showed that less than a tenth of respondents mentioned religion as a concern for their unwillingness to donate or receive donated breast milk, unlike in the Turkey study where a sizable proportion of mothers surveyed expressed religion as a barrier to acceptability of the concept of DBM [14]. To reduce or completely eradicate the distracting influence of religion on the well documented benefit of breast milk, relevant government authorities needs to involve faith and religious leaders in the campaign for DBM in order to eliminate religious prejudices and increase the acceptability of the concept.

Other reasons for unwillingness to receive donor breast milk documented in our study includes cultural unacceptability, unhygienic preparation, societal stigma, generally unacceptability, fear of transmission of bad genetic traits etc. These are realistic and honest concerns that can be allayed through targeted enlightenment programs and sharing of real-life success stories.

Due to the setting where this study was conducted, it is worth mentioning that the willingness to donate or receive donor breast milk was significantly associated with spousal consent even though the association lost significance on adjusted logistic regression analysis. Several studies in Nigeria and other developing countries have reported that most women seek permission from their spouse for use of health-related facilities [17‐19]. The need for consent by women from their spouses for health-related matters in most developing settings is an unfortunate but unsurprising fact in a patriarch society like Nigeria where polygamy is common and women are usually dependent on their spouse for most decisions due to inequalities in income and age. To the best of authors knowledge, no study has specifically investigated the association between willingness to donate/receive donor breast milk and spouse consent in a developing setting.

We found that knowledge of the donor breast milk concept, not being interested in financial compensation for donating breast milk and preference of donor breast milk over infant formulas were predictive of the mothers that would be potential breast milk donors. This is in line with the findings from a similar multi-center study in eastern Ethiopia which showed that acceptance of donor milk banking was more likely among mothers who had heard about donor milk banking and wet-nurses [20]. Another study in Rio de Janeiro, Brazil found that enhancing the understanding of the donor breast milk concept through encouragement by healthcare professionals, relatives, or friends, receiving information on breast milk expression by the primary health care unit, and receiving help from the unit professionals to breastfeed were associated with a higher prevalence of breast milk donation [21]. These findings are hardly surprising as conceptual understanding of a program or concept causes acceptance and participation where appropriate.

Furthermore, our study noted that mothers without monetary motives were more willing to donate their breast milk compared to those that require financial remuneration. Fortunately, only a small proportion of mothers in our survey indicated interest in monetary compensation before donating their breast milk. This is particularly not unexpected in a developing country like Nigeria where people donate their blood for financial gains [22] and where, over 65% women live in extreme poverty [23]. Financial remuneration for breast milk donation has been the subject of continuing research which has produced some conflicting results. Nonetheless, the Human Milk Banking Association of North America (HMBANA) endorses non- profit donor milk banking to ensure that a valuable healthcare resource is allocated in an ethical and safe manner, keeping the safety and needs of the recipient and donor paramount [24]. In addition, HMBANA has identified several problems associated with introducing the profit motive to milk banks. These includes adulterating milk to increase volume and placing the infant of the lactating mother at risk if she feels pressure to provide a certain volume of milk to a bank or a recipient rather than feeding her own infant [19]. Bloom noted in a study that adulteration of milk for financial gain led to rejection of 73 out of 4935 breast milk donations and that the dilution rejection rate was significantly higher in donors that required financial remuneration [25]. Also, Keim et al. reported that in 102 purchased samples advertised online as breast milk, eleven contained bovine DNA and ten of these had a level of bovine DNA consistent with human milk mixed with at least 10% cow’s milk [26].

Finally, we reported that mothers who would prefer donor breast milk over infant formula for their newborns in situations where they cannot breast their own babies were more likely to donate their breast milk compared to those that favored infant formulas. It is reasonable to assume that mothers that prefer donor breast milk over infant formula would most probably have reasonable knowledge of the social, economic and health benefits of breast milk and would naturally be more willing to donate their own breast milk for mothers and infants in need. The World Health Organization recommends donor breast milk as the next preferred option in situations where women are not able to provide their infants with enough amounts of their own breast milk [27]. Unfortunately, developing countries lag the rest of the world in establishing and promoting human milk banks. As a matter of fact, there is currently no functional human milk bank in the whole of the West African sub-region [28].

In conclusion, our study found that the knowledge of the concept of donor breast milk and awareness of policies recommending its practice in Nigeria is low, but the prospect of its acceptability is high among mothers surveyed in south-east Nigeria. Targeted public enlightenment and education to mothers and their families by relevant government agencies in collaboration with clinicians, community and religious leaders about the concept of donor breast milk may help increase the acceptance and practice of donating breast milk and/or use of donated breast milk among mothers in the region.