The Profile of Donors to a Human Milk Bank in a Developing Nation

Introduction

The number of preterm births is on the rise across the globe. ¹ A significant load of preterm births is concentrated in low- and middle-income countries (LMICs) such as those from the sub-Saharan and the south-east Asian regions. ¹ One of the most important interventions to improve the outcomes of these vulnerable preterm neonates is the use of human milk. Studies have shown that exclusively breastfed infants have only 12% risk of death in the first 6 months of life due to infectious diseases in LMICs compared to their counterparts who were not breastfed at all. ² However, many of the neonates (especially the preterm ones) who are admitted to the neonatal intensive care units (NICUs) are deprived of their own mother's milk due to a variety of reasons. In such scenarios, various authorities, including the World Health Organization (WHO), American Academy of Pediatrics (AAP), and The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), recommend the use of donor human milk as the second choice.^3–5 Multiple studies have shown that donor milk use is associated with a decrease in incidence of the dreaded complication of Necrotizing Enterocolitis that affects predominantly the preterm neonates.^6,7

The concept of human milk banking originated a century ago with the first milk bank being established in Austria in 1909. ⁸ Most of the developed nations of the globe have expanded their chain of milk banks in the past few decades. However, human milk banking is still in its infancy in many of the LMICs such as India. ⁹ Brazil, as a country is a notable exception, having established one of the most thriving human milk bank chains. ¹⁰ The first human milk bank in India was established in 1989 in Mumbai. There are around 50 milk banks, in total, in India as of now, which is grossly inadequate to meet the needs of a country with ∼27 million annual births, including 3.5 million preterm births (highest for any single country across the globe). ¹⁰ Recognizing this enormous need, the Government of India launched the “National Guidelines on Comprehensive Lactation Management Centres (CLMCs) in Public Health Facilities” in July 2017. ¹¹ There are certain questions that arise in minds of health care providers and the other stakeholders involved in the setting up of a milk bank in a LMIC, one being who will donate their milk altruistically in a developing nation? Most of the published studies on the profile of donors of human milk banks have been from the high-income countries.^12–15 There is a dearth of literature on the donor profile of human milk banks from a LMIC. This study was planned to address this lacuna.

Methodology

This was a retrospective chart review of the donors from the National Human Milk Bank of a LMIC from June 7, 2017, to February 28, 2019. This CLMC of which the National Human Milk Bank is a part was established in June 2017 with the support of Oslo University Hospital, Oslo, Norway, under an academic exchange program supported by NOREC, Norway, aiming at improved newborn care. This has been established at a tertiary care center, which has two Level III NICUs catering to predominantly intramural newborns and was envisaged as the National Reference Human Milk Bank, which would be involved in training, research, as well as providing technical assistance to the setting up of other human milk banks throughout the country.

The protocol was approved by the Ethics Committee for Human Research (ECHR), Lady Hardinge Medical College, New Delhi. Informed consent was obtained from the donors before enrolment as a donor. Demographic, social, and maternal details were recorded in the milk bank register. All the donors who had donated their milk to the milk bank, including those from community, during this study period were included. The primary objective of the study was to classify the donors based on the various demographic variables namely age, parity, mode of delivery, place of origin, birth weight, and gestational age at delivery of the donor's neonates. The secondary objectives of the study were to study the proportion of milk donated by the donors of the various subgroups, the mean volume of milk donated by each subgroup of donors, and the comparison of the mean volume of milk donated by the different categories of donors.

The data were analyzed using the SPSS software version 21.0. The frequencies and percentages of the various subgroups of donors were calculated. Student's t-test was used to compare the means. A p-value of <0.05 was taken as statistically significant.

Results

A total of 23,640 mothers delivered during the nearly 21-month study period, and of these, there were 5,314 (22.5%) admissions in the two NICUs. There were a total of 1,553 donors during this time period. Around 6.6% of the mothers who delivered within the hospital donated their milk at least once to the human milk bank. About 10.9% of the mothers whose babies were admitted in the NICUs donated their milk at least once to the human milk bank. The mean age of the donors was 21.6 ± 2.7 years. Almost 88% of the mothers were of the age group less than 25 years. Out of the 1,553 donors, 674 (43.4%) were primiparous mothers. While 56% (870 out of 1,553) of the donors had delivered vaginally (including assisted vaginal), 44% underwent a Caesarian section. Nearly two-thirds of the donors (63%) were from the postnatal ward and 37% were those whose neonates were admitted in the NICUs. The mean gestational age of the neonates of the donors was 35.5 (±3.6) weeks. The mean birth weight of the neonates of the donors was 2,175 (±748) g. Eight hundred twenty-seven (53.3%) out of the total 1,553 donors had delivered prematurely, giving birth to preterm infants. Approximately 13% of the donors had delivered at a gestational age of less than 32 weeks. Almost half (50.6%) of the donors had delivered low birth weight (LBW) neonates and around 20.7% of the donors had delivered an extremely low birth weight (ELBW) (<1,000 g) or very low birth weight (VLBW) (1,000–1,499 g) neonate. The demographic details of the donors are summarized in Table 1.

Around 413 L of human milk was donated to the milk bank by the donors during this time period. Out of the 413 L, 257 L (62.3%) was donated by the mothers whose babies were admitted in the NICUs and the remaining 156 L (37.7%) was by the postnatal care ward mothers. The mean quantity of milk donated by the donors was 268 ± 386 mL. The mean amount of milk donated by the mothers of the babies whose neonates were admitted in the NICUs was significantly higher (313 ± 468 mL) when compared to that donated by the postnatal care ward mothers (215.9 ± 252.6 mL) (p = 0.0001). A total of 271 L (65.5%) of the donated milk was from mothers who had delivered prematurely and 86 L (20.8%) was donated by mothers who had delivered an extreme or very preterm neonate (<32 weeks gestation). There was no statistically significant difference between the mean amount of milk donated by a mother who had delivered an extremely preterm neonate (<28 weeks gestation) when compared to those who had delivered very preterm neonates (28–31 6/7 weeks gestation) (p = 0.18). A total of 275.3 L (66.7%) of milk was donated by the mothers who had delivered a LBW/VLBW/ELBW neonate, and around 97 L (23.5%) was from donors who had delivered neonates <1,500 g. There was no statistical difference between the mean amount of milk donated by a mother who had delivered VLBW neonates when compared to those who had delivered ELBW neonates (p = 0.24). The quantity of milk donated by the different subgroups and their comparison are summarized in Table 2.

Discussion

This was a study done from a Human Milk Bank attached to a National CLMC from a developing nation in the first years after its inception. A total of 413 L of milk was donated by 1,553 donors over a time span of 21 months. Sachdeva et al. in their analysis of milk banks from a developing nation had estimated that a public sector milk bank enrolls a median number of 1,938 donors and collects a median volume of 498 L of milk annually. ¹⁶ The number of donors and the amount of milk collected by the index milk bank were lesser compared to those studied by Sachdeva et al. This might be attributable to the important fact that the index CLMC supports lactation to empower the mothers of the neonates admitted in the NICU and sends the freshly pumped milk to the NICU for feeding the individual mother's milk to her biologic baby and tracks mother's own milk (MOM) and pasteurized donor human milk separately for all NICU babies, aiming at maximizing MOM and not just “human milk.” Second, this study is conducted in the initial stages of starting the milk bank compared to the milk banks studied by Sachdeva et al., which were all well established. Quitadamo et al. in their retrospective study on human milk bank donation from a high-income country had noted that about 2,236 L of milk from 659 donors was collected over a period of 7 years (annual donors—94 and annual volume—319 L). ¹² It is evident that, although the number of donors enrolled by a human milk bank is far lesser in a high-income country compared to a LMIC, the volume of milk donated is almost comparable. This is most likely because of the fact that many mothers donate longitudinally over a longer duration of time in these high-income countries compared to those in a LMIC where cross-sectional donation is more common. ¹⁷

Most of the mothers who had donated were of the age group <25 years (88% of the donors) and the mean age of the donors was 21.6 (±2.7) years. Pimenteira Thomaz et al. in their cross-sectional study from the tropical nation of Brazil had noted that about 60% of the donors of human milk banks belong to the age group of less than 25 years. ¹⁷ However, studies from developed nations have reported the mean age of human milk donors to be between 31 and 33 years.^13,14 This difference in age can be explained by the fact that many women get married at a younger age in LMICs compared to high-income nations. It is also evident from the donor profile of the index milk bank that non-primiparous mothers and also those who had delivered vaginally are more represented than primiparous mothers and those who had undergone Caesarian section. However, Meneses et al. in their study on factors associated with human milk donation from Brazil had found that neither parity nor the mode of delivery plays a significant role in delineating donors from nondonors. ¹⁸ The index milk bank collects milk predominantly from mothers in the postnatal care wards and from those whose babies are admitted in the NICUs. While about two-thirds of the donors were from the postnatal care wards, one-third were from those whose newborns required NICU admissions. Sachdeva et al. had noted that only 6 out of the total 16 human milk banks studied from a tropical nation had home-based and community-based donors. ¹⁶ Similar to that reported by Pimenteira Thomaz et al. from their study from Brazil, almost half of the donors of the index human milk bank had delivered preterm neonates. ¹⁷ This is in stark contrast to that described by Quitadamo et al. from Italy where only 5.7% of the total donors had delivered preterm babies. ¹² Sierra-Colomina et al. in their study on the characteristics of donors from Spain had noted that around 23% of the donors were those who had delivered preterm babies. ¹³ It is quite evident that preterm donors are more common in LMICs compared to high-income countries. It is very well known that preterm milk has higher protein content when compared to term milk and since most of the recipients of the donor human milk are preterm neonates, this donor profile in LMICs might be more beneficial to its recipients. ¹⁹

The analysis of the quantity of human milk donated by different subgroups reveals that 62.3% of the total amount of milk donated to this human milk bank came from mothers whose neonates were admitted in the NICUs. This further reiterates the fact that the mothers whose neonates are admitted in the NICUs can not only provide milk for the needs of their own babies but can also contribute to the milk bank. This is by no means disregarding the contribution of mothers from postnatal wards, which is important for the self-sufficiency and adequacy of a newly established human milk bank. While 53.3% of the donors had delivered premature babies, 65.5% of the total milk was donated by them. About 20.8% of the donated milk came from mothers who had delivered very and extremely preterm neonates of gestational age <32 weeks. Quitadamo et al. in their study on preterm milk donation had reported a similar proportion of milk donation from this category of mothers who had delivered at <32 weeks gestation, which was 15.8% of the total milk donated in their milk bank. ¹² However, while the proportion of donors who had delivered at a gestational age of <32 weeks was 13% in the index human milk bank, it was much lower in Quitadamo et al.'s study, which was just a meager 3.3%. The mean volume of milk donated by the donors of the studied human milk bank was only 268 ± 386 mL. Studies from high-income countries have reported much higher amount of milk being donated per donor, anywhere from 3.1 to 18.1 L.^13,15,20 This significant difference exists as most donors from LMICs are first-time donors (donating while they are in the birthing facility), whereas those in high-income countries are long-term longitudinal donors from the community. This also further emphasizes the need to spread awareness among the general population about the importance of human milk donation through counseling sessions by health care professionals and through various mass media and social media platforms in LMICs where the need for donor human milk is much higher. Pimenteira Thomaz et al. had studied the influencing factors that motivate a mother in a middle-income country to donate to a human milk bank and had found that almost half of the donors were motivated by a health care provider, donor's family and friends, or advertising and/or news broadcasting. ¹⁷

The subgroup analysis also revealed that the mean volume of milk donated by mothers whose babies were admitted in the NICUs (313 ± 468 mL) was significantly higher than that donated by the mothers of postnatal care wards (216 ± 253 mL) (p = 0.0001).

While the mothers whose neonates are admitted in the NICUs stay for a longer duration of time in the hospital, those from the postnatal care wards are discharged early. The milk output of a mother is known to increase during the course of the first 2 weeks. This might be one of the reasons for the increased mean volume of milk donated by the NICU mothers. The other reason might be that these donors whose neonates are admitted in the NICU might have the opportunity to donate more number of times than those in the postnatal care wards.

The main strength of this study is that it is one among the very few studies from a LMIC that tried to dwell upon the demographic characteristics of the donors of a newly established human milk bank. This not only apprises the health care worker as to what to expect in the initial years after establishing a human milk bank in a LMIC but also paves way for improving certain aspects of milk donation in the developing world, such as augmenting efforts at improving home-based and community-based donations and increasing the number of longitudinal long-term donations. The limitation of our study is its retrospective nature. Also, some demographic parameters such as maternal education and economic status of the donors were not studied.

Conclusion

There are many inferences that can be drawn from this study. The most encouraging of them being that newly set up human milk banks in LMICs become sustainable even in the first couple of years after their establishment. It is also evident from this study that the donor profile of a human milk bank from a developing nation is very different from that of a high-income one in which, most of the donors are of a younger age group, are more likely to have delivered a premature or a LBW baby, and are mostly the ones who are either admitted in the hospital in the postnatal care wards or whose neonates require NICU admission. This study also reveals that the average milk volume donated by the donors is much lesser in a LMIC as most of them are cross-sectional donors. This highlights an important aspect related to augmenting efforts to motivate these first-time donors through various platforms to continue donating over a period of time.