Peer-to-Peer Human Milk Sharing: Recipient Mothers' Motivations,Stress,and Postpartum Mental Health

Abstract

Background:

Some mothers who cannot breastfeed—partially or completely—choose to feed their infants human milk donated from a peer. Few studies have examined mothers' experiences with using donor milk; none has examined whether or not mothers' stress and mental health are associated with using donor milk from a peer.

Methods:

Researchers conducted semistructured individual interviews with mothers from the United States and Canada (N = 20) to answer the following questions: (a) what are recipient mothers' motivations for participation in peer-to-peer breast milk sharing and (b) what is the relationship between receiving donated milk and mothers' stress and mental health postpartum? Transcripts were coded using an inductive approach and principles of grounded theory were used to analyze data.

Results:

Data were organized under two themes: (a) motivations for using milk from a peer and (b) milk-sharing and stress-related experiences. Motivations included health benefits, medical need, and preference for human milk over formula. Factors inducing stress were as follows: logistical stressors of securing donor milk and fear of running out of milk. Factors reducing stress were as follows: donor milk provided relief and comfort and its use reduced mothers' self-reported symptoms of postpartum depression and anxiety.

Conclusions:

Mothers participated in peer-to-peer breast milk sharing primarily because of health benefits for children. However, participation also had important psychological benefits for some mothers. Additional research and open discourse are needed to support mothers who choose to use milk from a peer and to promote safety of this practice.

Introduction

Breastfeeding and stress

Breastfeeding is the biological norm and the risks of not breastfeeding are abundant.¹ Children fed breast milk substitutes have inferior immune system development and an increased risk of illness, chronic disease, and premature death; mothers who do not breastfeed recover from childbirth slower and have higher rates of diabetes, breast and ovarian cancer, and poorer mental health when compared to breastfeeding women.^2,3 While breastfeeding-related challenges are associated with increased physical and psychological stress among mothers,⁴ a rich literature base demonstrates that successful breastfeeding is correlated with reduced stress, and lower rates of anxiety and postpartum depression (PPD).^5,6

The field of psychoneuroimmunology purports that breastfeeding may support positive mental health by complex pathways resulting in reduced bodily inflammation, regulation of the hypothalamatic-pituitary axis, and improved cellular immunity.^7–9 In addition, psychological factors, such as high breastfeeding self-efficacy—or the belief that one has the ability to successfully breastfeed—may play a role in reducing rates of PPD.¹⁰ However, not all mothers can or choose to breastfeed their children. Mothers who do not breastfeed and those who do not meet their breastfeeding goals are more likely to have higher biomarkers of stress, report higher levels of personal stress, and experience PPD.⁵ Mothers who intend to breastfeed, but who do not successfully reach their breastfeeding goals may be at highest risk for PPD.¹¹

Peer-to-peer human milk sharing

Some mothers who are unable to breastfeed seek donor breast milk to feed their children. Mothers' substantial desire to provide breast milk to their children, despite breastfeeding challenges, is a primary factor for using donated breast milk.¹² Some mothers purchase regulated and pasteurized human milk from a milk bank. However, this milk is often prioritized for preterm and/or medically fragile infants.¹³ Furthermore, there are many barriers to accessing milk from a bank—for example time for travel, transportation, and cost.^14,15

In addition, some mothers purposefully choose not to use milk from a bank, in favor of nonpasteurized milk from a peer. This type of breast milk sharing—through unregulated social networks—has become a common practice across the globe.^16,17 This phenomenon is called peer-to-peer breast milk sharing (PBMS) and refers to the donation and receipt of human milk for altruistic purposes (as opposed to monetary gain), among friends, family, and/or through online social networks. The prevalence of PBMS is unknown. While it appears to be a growing practice,¹⁸ participants likely account for a small minority of the population.

PBMS is not without controversy. While human milk is commonly recognized as the ideal food for infants, there are well-publicized safety concerns about sharing milk between peers, outside of a formal, regulated milk bank. In the United States, The American Academy of Pediatrics (AAP), United States Food and Drug Administration (USFDA), and Centers for Disease Control and Prevention (CDC) strongly caution against the sharing and use of unpasteurized donor milk through informal social networks because of potential contamination risks.^19–21 Furthermore, the media has played a significant role in framing mothers who choose to participate in PBMS as irresponsible and ill-informed. Carter et al. completed a discourse analysis of 30 articles from top circulating newspapers reporting on milk sharing in the United States and critiqued conflicting messages about breastfeeding and breast milk sharing.²² They concluded that breastfeeding and breast milk acquisition through regulated banks have been viewed as beneficial and morally commendable; on the contrary, PBMS has been touted as inherently risky and even downright dangerous.

However, proponents of PBMS argue that while there are inherent risks in sharing milk, there are also risks to feeding breast milk substitutes.^1,23 When employing risk mitigation measures, the benefits of sharing milk—especially when compared to infant formula as an alternative—may outweigh potential dangers.²⁴ To our knowledge, there have been no documented cases of children getting ill from shared human milk. In addition, there is no research examining the health of children fed partially or wholly using unpasteurized milk donated from a peer. There is reason to believe—based on literature demonstrating the inferiority of human milk substitutes compared to breastfeeding and the provision of human milk—that infants and children whose mothers participate in PBMS may have superior health outcomes when compared to infants who do not receive human milk. While a need exists to promote safety in PBMS, there is also room to investigate all potential benefits of this practice.

This study

Little research exists examining mothers' experiences with PBMS. Since many mothers pursue donated milk from peers, despite previously stated safety concerns, it is important to understand their reasoning and experiences. Furthermore, we are unaware of any research examining any potential relationship between PBMS and mothers' stress and mental health. Therefore, this study sought to

(1)

Explore mothers' motivations for participation in PBMS; and

(2)

Examine the relationship between receiving donated breast milk and mothers' perceived stress and maternal mental health postpartum.

Methods

This study is part of a larger qualitative, descriptive, and exploratory research protocol designed to understand PBMS broadly from the perspective of recipient mothers. A phenomenological approach guided open inquiry to participants' unique experiences and communication of meaning²⁵ of the little understood phenomenon of PBMS. The study was determined exempt from full IRB review by The Office of Responsible Research Practices at The Ohio State University.

Sample recruitment

The participants for this study were recruited through the Facebook site for Human Milk 4 Human Babies Global Network (HM4HB), an online community where interested participants connect to share human milk.²⁶ HM4HB does not arrange exchanges of human milk, but provides an online space for interested parties to connect, develop relationships, and communicate for milk exchange. HM4HB has a global reach and its volunteers maintain regional Facebook pages. For the purposes of this research, women were eligible to participate if they were 18 years of age or older, were English speaking, and had received human milk from a peer to feed their child within the previous year. Exclusion criteria included pregnancy, and women who participated in human milk sharing as donors only. Although mothers from any country were eligible to participate in the study, only those currently living in the United States and Canada responded to the invitation.

Procedures

The first author shared a study recruitment flyer with HM4HB. HM4HB shared the flyer on its global network Facebook page; some individual U.S. state pages then shared this flyer also. Individuals interested in volunteering for the research study contacted the first author who confirmed eligibility criteria, scheduled each interview, and distributed informed consent forms through email. Before the start of the telephone interview, the consent form was reviewed. Participants provided verbal consent and interviews proceeded immediately thereafter. Pseudonyms were used to protect anonymity.

A phenomenological approach (See Supplementary Data for complete Interview Guide) was applied to develop a semistructured interview guide. Closed- and open-ended questions were used to collect basic demographic data and inquire broadly about mothers' experiences with PBMS, reasons for participation, benefits, and challenges faced. Mothers were also asked about experiences of stress and symptoms of PPD. Each participant took part in one telephone interview. The first author, a masters-level social worker with several years of clinical practice experience, completed all interviews from February through May 2017. Interviews were recorded and transcribed verbatim.

The first author carefully questioned participants as they shared private experiences about PBMS. She used a neutral stance to elicit the meaning and significance of their described milk sharing experiences and ensure that their voices and perspectives were highlighted during data collection and analysis. The author expressed empathy, nonjudgment, and openness to the unique experiences and viewpoints about PBMS. To ensure rigor and reflexivity in the qualitative research process, the author also maintained a journal and wrote memos of her own personal experiences, while collecting data. She bracketed her personal experiences and carefully listened to her respondents. She used probes occasionally to better understand the respondents' experiences.

Data analysis

Participant demographics and characteristics were recorded using an electronic spreadsheet. All other data were managed using NVivo Pro 11 for Windows software.²⁷ Transcripts were read multiple times to get increased familiarity with participants' experiences. The first author completed all the initial coding of the data. The second author provided reflective listening and thoughtful and constructive feedback, and encouraged critical review of interpretations throughout the data analysis process. To increase rigor, researchers intentionally identified data that conflicted with the findings (negative case analysis), and peer debriefing was used throughout the data analysis process to increase validity of the findings.^28,29

The predetermined topics of (a) mothers' motivations for participation in peer-to-peer HM sharing and (b) the relationships between peer-to-peer HM sharing and mothers' postpartum stress and mental health served as broad categories under which emergent themes were organized. Principles of grounded theory explained by Strauss and Corbin were used to analyze and interpret data; open, axial, and selective coding were completed using an inductive approach.³⁰ For the purposes of this article, participants' comments were coded only if they related to the research questions—motivations for participation in PBMS and the relationship between receiving donated breast milk and mothers' perceived stress. The first author maintained an audit trail of all participant communication and ongoing impressions of the data and notes related to decisions made about codes and themes throughout the data analysis process.^28,29 The researchers met biweekly to review themes. Discussion and reorganization of codes into final themes continued until mutual agreement was reached.

Findings

The sample was 16 biological and 4 adoptive (N = 20) mothers from the United States (n = 18) and Canada (n = 2), who had been recipients of PBMS within the past 1 year. Twenty respondents was an appropriate sample size because it enabled for saturation—the lack of new insights in response to questions as well as the lack of newly emerging codes³¹—and fell within recommended guidelines for phenomenological inquiry.^32,33

See Table 1 for participant demographics. Most participants were from the United States and half were from Midwestern states. The majority identified as white and were married and college educated. Respondents' ages ranged from 21 to 47 (M = 32.2) and household incomes ranged from $30,000 to $300,000 (M = $105,684) U.S. dollars. Half of the sample first accessed donor milk by a friend, family member, or a birth professional (e.g., midwife, doula, and nurse); half first accessed donor milk from a peer they met on the Internet. Two respondents used a formal milk bank before participating in PBMS. Notably, half of the sample continued to breastfeed and/or continued to express breast milk throughout the time they participated in PBMS. In addition, half of participants reported having experienced PPD; some self-diagnosed their symptoms and others had a formal diagnosis from a medical professional. See Table 2 for details about key themes that emerged, codes that were associated with each theme, and example quotations.

Table 1.

Participant Characteristics (N = 20)

Characteristic	n (%)
Maternal age
21–25	2 (10)
26–30	7 (35)
31–35	6 (30)
36–40	2 (10)
>40	3 (15)
Relationship to child
Adoptive mother	4 (20)
Biological mother	16 (80)
Race/ethnicity
White	18 (90)
White/Puerto Rican	1 (5)
Hispanic	1 (5)
Education level
Less than high school	1 (5)
High school or equivalent	1 (5)
Some college	5 (25)
College graduate	5 (25)
Graduate coursework	8 (40)
Relationship status
Single	1 (5)
Long-term relationship	4 (20)
Married	15 (75)
Region of Residence
Canada: British Columbia	2 (10)
United States: Northeast	1 (5)
United States: Midwest	10 (50)
United States: South	3 (15)
United States: West	4 (20)
Household income
<$50,000	2 (10)
$50,000–$99,999	7 (35)
$100,000–$150,000	7 (35)
>$150,000	4 (20)
Continued to breastfeed and/or express milk	10 (50)
PPD: Diagnosed or self-report	10 (50)

Regional divisions of residence defined by the U.S. Census Bureau.

HM, human milk; PPD, postpartum depression.

Table 2.

Key Themes and Examples of Quotations

Categories	Theme	Theme description	Example quotation	Examples of codes
Motivations for using donated human milk from a peer	Human milk's superior health benefits	All mothers said that the health benefits of human milk motivated them to seek donor milk. Examples of health benefits noted were immunological and nutritional.	I really wanted to have all the nutritional benefits of breast milk, all of the antibodies in breast milk that sort of thing…The baby gets the benefit of having the antibodies and um, that perfect nutrition from breast milk.	Liquid gold; best nutrition, health, immune system, antibodies, healthy, natural, best thing, protection
	Medical need	A few mothers reported that their children required breast milk to best manage and/or recover from health problems. Some were advised to only provide breast milk by their physicians.	…benefits were really specific for us because of [son's name]…disease. I didn't want to put a shock to his system of trying formula, of which he's never had before and I wouldn't know the consequences without trying it…So, formula, or anything like that wasn't really ever an option for us.	Medical condition, healing, rebuild immune system, recover, healthy development
	Preference for human milk over breast milk substitutes	Mothers noted a strong preference to feed their children breast milk, even if not their own. In addition to a preference for human milk, mothers noted strong concerns about the risks and limitations to formula feeding as a substitute.	…when the moment came when I couldn't [breastfeed], it was very, it just felt like a crisis. And so, breast milk seemed, you know, donor milk seemed like such a better option to me than formula… from researching I was really concerned about the sugars and other things in American formula.	Prefer breast milk over formula, second best to breastfeeding, health risks of formula/not receiving breast milk, donor milk best option, babies should have breast milk
Factors inducing stress	Planning and coordination to secure donor milk	The planning and coordination required to secure donor milk were reported as a practical and emotional challenge by mothers. In addition, mothers said that these logistical efforts required a lot of time and commitment.	…one of my donors in the beginning was 45 minutes to drive one way. So that's a long time for a little baby to be in the car on a regular basis. Even for me as a new mom, I was so tired sometimes. So the driving is an aspect too.	Keeping up with getting it; making arrangements, connecting with people, asking questions, traveling, planning, logistics, time consuming
Factors inducing stress	Fear of running out of donor milk	Some mothers reported anxiety or stress related to maintaining a regular supply of donor milk. There was a fear that they may not be able to secure enough milk to meet their child's needs.	When we get a little bit low, like right now, I am a little bit stressed out. I know we have formula as a backup, but it helps to have a lot of extra breast milk in the deep freezer just so we are set.	Running low, end of freezer stash, having enough, 2 weeks' worth left, counting bags
Factors reducing stress	Donor milk provided relief and comfort	Mothers said that using donor milk was comforting because they did not have to compromise their beliefs about providing breast milk for their children. It also provided stress relief from worries about children not receiving breast milk.	It [milk sharing] works for me, takes anxiety away from me. Gives the best nutrition that my baby can have.	Relief, helped stress about feeding, donor milk fit with beliefs, felt good to give baby the food she's supposed to have, good stuff, best nutrition, getting nutrients needed
Factors reducing stress	Donor milk use decreased symptoms of postpartum depression and anxiety	Mothers suggested that utilizing donor milk reduced or provided protection from symptoms of postpartum depression and anxiety. Donor milk use increased mothers' support networks, aligned with beliefs about infant feeding, and reduced some sadness associated with being unable to reach breastfeeding goals.	Milk sharing completely reduced it [postpartum anxiety]. That's the only anxiety I had, was how am I going to feed my baby. And then people would come through and give me milk and it just took it away. It made that challenge go away.	Reduced depression, less anxiety, not being able to breastfeed was sad, traumatic, social network

Interviews ranged from 25 to 90 minutes; most interviews lasted approximately 45 minutes. Some respondents shared emotionally charged health- and breastfeeding-related challenges. In addition, while many participants had support for their decision to use milk from a peer, some described painful experiences of stigma, misunderstanding, and judgment.

Motivations

For the participants in our sample, various situations—breastfeeding challenges, breast milk pumping challenges, mothers' and/or children's health conditions, and adoption—led to the decision to use donated breast milk. Some respondents used donor milk to supplement their own breastfeeding or milk expression. In fact, about half said they continued to breastfeed and/or express milk, while also using donated milk. Other participants used PBMS to provide all of their child's nutrition. Two participants said they used donor milk to supplement formula feeding. The primary motivations for choosing PBMS are represented by the following themes: (a) human milk's superior health benefits; (b) medical need; and (c) a preference for human milk over formula substitutes.

Human milk's superior health benefits

Overwhelmingly, the numerous health benefits of utilizing breast milk to feed children were emphasized. Respondents described human milk as “liquid gold,” and said the personal choice to use donor milk from a peer was “best for my kid.” Respondents frequently commented on the nutritional, immunological, and health-boosting properties of human milk:

I wanted her to have the nutrition of breast milk, but wasn't really capable to produce myself. I know it's [inducing lactation] possible, but that looked pretty overwhelming in this situation [adoptive parent]. So, when I found out, you know, that I could have the benefits of breast milk through a donor…I jumped on that.

The immune benefits that they get from breast milk far outweigh any potential risk. And it's really what I wanted her to have. It's what babies are supposed to have and it wasn't something I could provide for her.

Medical need

A few study respondents explained that their children had medical conditions that further emphasized the need for human milk as opposed to breast milk substitutes. Some said that physicians recommended human milk, and in some cases, said their children would not tolerate anything else. Human milk was viewed as a requirement and also a support for child's recovery and healing.

…he was born substance-exposed…And, so…especially with him, I feel that any opportunity we have to contribute to healthy development, healthy brain, you know, brain growth, healthy, you know, all of it…To give him the best start in life and the best opportunity to work passed some of those issues—you know, he had some signs of withdrawal, which we worked through…the breast milk really gave him an opportunity to really enrich that healing, in a sense.

I have a baby born full term, but, um, has a medical condition that we're going to be doing surgery for him…and he needed to be on breast milk to really build his immune system. The doctor said, ‘you know, we really need you to be dedicated to breastfeeding,’ but I knew my history wasn't going to allow me to. And so, that's when I started peer-to-peer [human milk sharing]…my son needed to be on it—for the antibodies and the nutritional benefit of it—and so, you know, I think that when you pasteurize, when you heat something up to a temperature, higher than what it's normally stored at or utilized at, there is some decline in the benefit of the actual milk.

This quote also refers to the preference of many participants to use unpasteurized donor milk. Some participants purposefully chose not to pursue screened and pasteurized milk from a bank because they said untreated milk provided maximized immunological benefits.

Preference for human milk over breast milk substitutes

Participants expressed a clear preference for human milk over formula. Human milk was noted to be “normal,” nutritionally superior, and healthiest infant feeding option, and free of side effects. Conversely, participants expressed concerns about formula risks, including allergies, digestive upset, and increased likelihood of illness.

I mean, the number one benefit is that your baby is getting breast milk as opposed to formula…I felt like there is more of a risk for her to develop allergies or symptoms from taking formula…For me, it's a last resort…

I was like, she was gagging now on formula….yeah, so she wasn't taking the formula very well…so I wanted to give breast milk and not do the formula thing…

…my first daughter was formula fed and she was constantly sick…had rashes, always had, had pneumonia a couple times, had tubes put in her ears right before she turned 2—always had ear infections. I was very worried that it [formula] would compromise my new daughter's immune system. I gave one bottle of formula before finding someone to get donated milk from and my baby immediately threw it up and I knew that I could not do that to her…She's has had no adverse reactions to any of the breast milk.

Some participants also said that they felt risks to using formula were higher than risks associated with using donated milk from a peer. One participant said, “I feel like the risks associated with factory produced, highly manufactured, formula, baby formula, as well as with other foods, is far riskier than acquiring breast milk.” Others—in addition to emphasizing human milk's superiority—simply stated a strong preference for utilizing human milk over substitutes: “I'm a strong believer in breast milk. I don't like the whole formula thing. I don't like formula companies…And the breast milk was just a much better option for me.”

Just a few respondents commented on the financial cost relative to PBMS. Two noted that cost savings played a role in choosing to participate. One participant said: “…the reason why I wanted to breastfeed myself was feeding my baby without the cost. So, that was my drive to breastfeed, but since I couldn't, that has been a benefit for our family, with peer-to-peer breast milk sharing.” In contrast, however, another respondent said there was a financial cost to using donated milk: “…we still replace [breast milk storage] bags so it still costs money. It's not free… I have to travel, at least an hour and a half away, to pick it [milk donations] up most of the time…if I were to say there is a financial benefit, I think that that would be wrong.”

Experiences of receiving donated human milk and mothers' perceived stress

While the motivations for PBMS were strong, the process of acquiring donor milk was oftentimes described in the context of stress. While participants identified stress-inducing factors, they also talked about how their stress was relieved by acquiring donor milk through PBMS. The stress-inducing factors related to PBMS are discussed first, followed by stress-reducing factors.

Stress-inducing factors

About half of the sample said they experienced stress related to PBMS. The two stress-inducing themes that emerged were as follows: (a) the logistical efforts—planning and coordination—required to acquire milk and (b) the fear of running out of milk before another donation could be secured.

Planning and coordination to secure donor milk

Participants most frequently noted stress related to the efforts required to obtain donated milk from a peer. For some, donor milk was not always easy to locate. In addition, the process required to find and acquire milk was sometimes time-consuming and required a lot of organization, communication, and travel.

I mean it does take some time. You kind of have to be like on the website, and jump in their first and stuff, to some extent, you know, which is a little difficult or you have to be willing to drive a lot.

I mean the challenge at the beginning was just finding enough. And also being able to go get it because I was by myself…

While participants expressed some angst and concern about the experience, they universally agreed that the benefits of using donor milk outweighed its stress-inducing features:

It was stressful to stay on top of the network and communicate with people and make arrangements and ask questions, and make the connections…and then do the traveling. But, that stress, the stress of not having had the breast milk would have been far greater than just the logistical stress of connecting with people, making arrangements, and doing the traveling. Yes, that was stressful, but not having the food that I feel my baby is supposed to have would have been a heck of a lot more stressful, you know.

Fear of running out of donor milk

Some participants said that a fear of running out of donor milk was stressful. They worried about being able to maintain a steady supply of donor milk to meet their children's needs without having to use a breast milk substitute.

There were some moments, I won't lie, that you get down to one freezer and you're thinking, “I have 2 weeks” worth of milk left. How am I going to feed my baby?’

And, you know, sometimes I was so close, you know, to having just enough. It was constantly just this game of cat and mouse where I'd be on the pump and trying to eke out just enough to get them through. That was incredible stress.

Stress-reducing factors

All 20 participants reported a reduction in perceived stress as a result of using donated breast milk from a peer. Two key themes emerged representing participants' responses: (a) donor milk provides general relief and comfort and (b) donor milk use reduced symptoms of postpartum anxiety and depression.

Donor milk provides general relief and comfort

Participants reported that using donor milk from a peer reduced symptoms of stress. This stress reduction was attributed to not having to compromise one's beliefs about the importance of providing children with human milk and an ability to provide children with the best nutrition possible. Respondents reported a general sense of relief and comfort in knowing their children could receive human milk, even if it was not all their own. Physically securing the milk relieved participants of worry about how they would feed their children otherwise. The use of donor milk also reduced participants' stress by providing children with health benefits, while also reducing formula-specific concerns.

So when I found this [milk sharing] was available, it really gave me piece of mind. Like I can still give her that quality without stressing myself out, you know?

I felt like I could breathe…There's this stigma of once you use the formula that it was kind of a slippery slope and I didn't want to go down that…It was just a stress relief 100% that I had that option.

It's been, it's helped me so much…And after I received donated milk it was easier on me because stress does affect, you know, your milk supply. So I was a little more relaxed. I started noticing that my supply was being affected in a positive way.

In noting the emotional relief that PBMS provided, participants also took pride in the ability to provide their children with human milk because of its nutrient and immune-boosting profile. Respondents emphasized knowledge imparted by health care professionals that breast milk is unquestionably the ideal food for infants: “I felt like it was kind of drilled into my head, the whole, ‘breast is best’ thing…You know even WHO [World Health Organization] and the AAP [American Academy of Pediatrics], they all say ‘breast is best.’” Many other participants echoed the sentiment that providing their children with the ideal nutrition was comforting.

I always felt like especially the few times she did get sick, I felt in my heart, like, ok, that I did everything that I can do for this little girl. I did feel really, really, good in my heart that I was providing for her, the best that I could. That, I hopefully wouldn't have to worry about her health in that way. It definitely brought me peace there.

But, um, it was kind of less stressful because I knew they were getting the nutrients they needed through breast milk while they were such tiny babies.

Donor milk use reduced symptoms of postpartum anxiety and depression

Half of the participants said they struggled with symptoms of depression and anxiety postpartum. Most attributed their symptoms to breastfeeding-related challenges. One respondent said, “I would say a large of percentage of the stress and or anxiety was related to breastfeeding challenges…” The inability to successfully breastfeed, partially or completely, and/or the inability to produce enough expressed milk when separated from their children caused emotional and cognitive distress. Participants described the experience of being unable to breastfeed as “disappointing, sad, traumatic, discouraging, stressful,” and “devastating.” Some said they felt as though they failed their children: “Well, it was just like, unbelievably traumatic…I mean not being able to breastfeed was the worst [emphasis added]. It was the most stressful experience I ever had…It was so emotional. I felt like I wasn't feeding my baby and failing it this very primal way. It was really, really hard.”

Many participants suggested that utilizing donated human milk may have supported positive mental health and even protected them from and/or alleviated some symptoms of PPD and anxiety. Stress, sadness, and anxiety were reduced by social support and connection with the donors, alleviation of worry about how to feed their children, and still being able to provide children with breast milk, which aligned with respondents' personal beliefs.

I think it just goes back to that social network… I was very worried about PPD. And I don't really feel like I had that because at 2 o'clock in the morning I was on Facebook with his Milk Mamas [donors] and they were up too, nursing their babies…We do, um, feeding on demand. We do a lot of skin-to-skin and I think all of those things help you bond and feel closer to your baby. And so I think that did help my hormone levels because I couldn't breastfeed so I wasn't getting the benefits of that physical nursing, but I could get some of those benefits. And I wouldn't have done that if I didn't have people who were there to help me and talk to me about it and share their experiences and their donated milk.

Looking back I probably was not in a great mental state…honestly breast milk sharing alleviated some of the stress of feeding her…I think if I had switched her to formula or started supplementing with formula, I was really worried about losing my supply completely if I did that…So, I think that would've really depressed me and made me feel like I failed her, at least at the beginning…it's hard to say what would've happened if I hadn't. But, I think it was positive.

Conversely, while one participant said choosing donor milk for her son reduced her stress, she did not attribute breastfeeding challenges or the use of donor milk with postpartum anxiety or depression: “I really didn't feel depressed that we needed extra milk…I knew that my body doesn't respond well to a pump and I knew it [solely providing breast milk for her son] wouldn't be an option for me.” While the optimal goal was to fully breastfeed and express milk themselves, participants said that using donor milk served as the next best option, aligned with their beliefs, and ultimately supported a more positive mental outlook: “Again, I'm very sad that I wasn't able to provide [breast milk] myself. Like, there would be so much satisfaction in being able to do that…But, I did the best I could in the fact that I pumped myself and I did what I thought was the next best step with donor milk.”

Discussion

Our study explored the motivations for participation in PBMS, as well as related experiences of stress and its influence on mental health, among recipient mothers. In concert with previous studies on PBMS, recipient mothers described human milk as the natural food that babies were meant to have; furthermore, they communicated a strong preference for human milk over breast milk substitutes because of its health and immunological benefits.^14,15,34 These findings further highlight mothers' substantial desire to provide their children with human milk, even when they are unable to partially or completely provide it themselves.¹⁵

In addition, we found that human milk sharing can simultaneously induce and reduce stress. Since milk sharing is still a relatively rare and unrecognized phenomenon,³⁴ finding donor milk can pose a challenge. Also, the logistical efforts required to secure available milk—communication, travel, and coordinating schedules—can be taxing. Once donor milk is obtained, many mothers worry about maintaining an adequate supply for their child's ongoing needs.

In terms of stress reduction, mothers reported psychological benefits of PBMS. Despite mothers' limited ability or inability to breastfeed or express milk themselves, they associated PBMS with pride, comfort, and relief in being able to provide their children with breast milk. Furthermore, respondents indicated that PBMS provided some protection or relief from postpartum stress, anxiety, and depression related to infant feeding. This is noteworthy finding as PPD represents a significant public health challenge.

In the general population, the 12-month period prevalence of PPD ranges from 9.6% to 14.5%.^35–37 In our sample, half of participants self-reported PPD symptoms. This high rate corresponds with previous research demonstrating an increased likelihood of PPD among women who intend to breastfeed, but are unable.^10,38 Our findings are in line with research suggesting a psychological component to PPD as it relates to breastfeeding—in addition to a biological and hormonal one. Additional research is needed to investigate this association in a larger sample and to examine potential mechanisms behind a reduced stress response and improved mental health.

To our knowledge, this study is the first to specifically examine the relationship between PBMS and experiences of stress and mental health postpartum. Findings highlight that mothers who intend to breastfeed, relactate, or induce lactation, but who are having difficulty doing so, need increased attention, support, and education from health care providers and lactation professionals³⁹—to support not just successful breastfeeding, but mothers' mental health. This also applies to mothers who are unable to breastfeed or experience breastfeeding challenges due to medical problems or adoption. In such situations, medical professionals often are quick to recommend breast milk substitutes without regard to short- and long-term health implications.² While some situations call for clinicians to support mothers in ceasing breastfeeding and lactation efforts to ease their anxiety, in other circumstances, it may be more appropriate to explore alternative infant feeding options (i.e., use of donor milk and inducing lactation).

Moreover, use of donor milk may salvage breastfeeding relationships. Many women in this study continued to breastfeed or express milk throughout the process of supplementing with donated milk. This is supported by previous research indicating that donor milk recipients maintain longer exclusive breast milk feeding rates than the general population.¹⁷ Participants in this study revealed that a resolute commitment to breastfeeding and milk expression combined with participation in PBMS provided motivation and encouragement to continue lactation efforts.

Overall, findings suggest that the advantages of PBMS extend beyond children's health. It is well known that not breastfeeding and not providing human milk have numerous negative health implications for mothers and their children.⁴⁰ This study adds to this understanding by acknowledging that for some mothers, donor milk provides a kind of psychological comfort that breast milk substitutes cannot. Study results further support the possibility that the benefits of safe PBMS may outweigh its risks.³⁴ This may be particularly true for a subset of mothers who are committed to breastfeeding and/or providing their children with expressed human milk, but who cannot fully meet these needs themselves. In this context, PBMS may allow an avenue for reducing postpartum stress, anxiety, and depression.

Despite contention, PBMS is a growing practice.¹⁷ Therefore, health care practitioners have an ethical obligation to understand the risks and benefits of PBMS and be able to provide families with this information, recognizing it as one possible infant feeding option.^14,41,42 Although mothers are well aware of messages promoting the superiority of breastfeeding and providing children with breast milk, they may not ask providers about PBMS because of its controversy. This represents a missed opportunity to educate about hygienic and safe milk sharing. Practitioners can aid in supporting mothers who feel strongly about providing their children with breast milk, but who may experience barriers in doing so by openly discussing donor milk—from formal and informal sources—as an infant feeding option. In doing so, they may be simultaneously supporting infants' physical health and mothers' mental health. The recently published Academy of Breastfeeding Medicine's 2017 Position Statement on Informal Breast Milk Sharing for the Term Healthy Infant provides a useful tool for providing education and guidelines to minimize risks and maximize potential advantages of PBMS.⁴³

Limitations

Our results should be interpreted with caution. Limitations of this study include a single form of data collection at one time point and potential researcher bias in interpretation of the results. Findings were also limited by the self-selected sample who responded to the recruitment flyer. PBMS research—this study included—has primarily investigated the experiences of cisgender white females who are partnered, college educated, and economically stable. While this may be reflective of the majority participating in PBMS,^13,16,22 research thus far has omitted the experiences of others who may participate (e.g., women of color, transgender individuals, and gay couples). Human milk sharing, as well as related experiences of stress and mental health, likely differs considerably for these groups.

Conclusion

In summary, PBMS provides an increasingly popular option for infant feeding among mothers who are unable to partially or completely breastfeed, but who strongly desire to provide their children with human milk. While mothers' primary motivation for using donor milk is the superior health and immune system benefits it can provide their children, our findings suggest that secondary benefits may include a reduction in mothers' stress, anxiety, and depression. This further validates the need to both continue to investigate the personal and public health benefits of safe milk sharing between peers. Since some mothers will continue to pursue PBMS despite advertised safety concerns, health professionals and researchers have a duty to dialogue with mothers about safe and hygienic milk sharing practices.

Footnotes

Acknowledgment

The authors thank all the mothers who graciously donated their time to participate in this research.

Disclosure Statement

No competing financial interests exist.

Supplementary Material

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Supplementary Material

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