JOGNN RESEARCH

Peer-to-Peer Milk Donors’ and

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

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

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

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
The cost imposed by some banks on recipient parents is a
strong disincentive to some women for donating milk to a
milk bank.
breast milk directly with one another outside of
any organization or system. Until very recently,
such peer-to-peer milk sharing required that moth-
ers in need of milk be personally acquainted with
mothers prepared to share milk. For this rea-
son, peer-to-peer milk sharing occurred sporad-
ically and on a small scale and has been the
subject of only scant research (Bar-Yam, 2005;
Thorley, 2009).
More recently, social networking via the Internet
has been used to connect mothers requiring milk
with those willing to donate human milk. There are
currently more than 170 such Facebook groups
across more than 50 countries. This use of so-
cial networking means that milk sharing can easily
occur between individuals previously unknown to
one another and on a large scale.
Some health authorities have been alarmed by
the phenomenon of direct milk sharing and have
warned parents to avoid peer-to-peer milk shar-
ing. These authorities have expressed concern
that the potential for disease transmission or
contamination of the milk is unacceptably high
(Agence Francaise de Securite Sanitaire des Pro-
duits de Sante; 2011; Health Canada, 2010; U.S.
Food and Drug Administration; 2010). Parents in
need of milk are advised instead to seek human
milk only from a milk bank.
However, in some regions milk banks have re-
ported milk shortages. These shortages have
been blamed on the advent of peer-to-peer milk-
sharing networks. It has been suggested that
women are donating milk to their peers in pref-
erence to milk banks, decreasing the volume of
banked donor milk available to milk banks and
therefore to NICUs (Dutton, 2011; Newman, 2011;
Rochman, 2011). Thus, peer-to-peer milk sharing
has been represented as depriving sick infants
of milk that might be necessary for their survival
(Newman).
As a part of a larger study examining Internet-
facilitated peer-to-peer milk sharing, women’s rea-
sons for donating milk to, or receiving milk from, a
peer rather than a milk bank were explored. This is
the first study to consider the experiences and per-
452 JOGNN, 42, 451-461; 2013. DOI: 10.1111/1552-6909.12220
ceptions of the women involved in Internet-based
peer-to-peer milk sharing.
Methods
A descriptive survey design containing closed
and open-ended questions was used to examine
women’s perceptions of peer-to-peer milk sharing
and milk banking. A convenience sample of peer-
to-peer milk donors and recipients was recruited
via advertisement on the Facebook pages of the
two largest milk-sharing groups, Human Milk 4 Hu-
man babies and Eats on Feets. By its very nature,
peer-to-peer milk sharing is highly decentralized,
and no records are kept of who is sharing milk with
whom. As such, obtaining a representative sam-
ple of this group was impossible. However, wide
advertisement of the study aimed to garner as di-
verse a sample as possible.
To be eligible to participate, individuals were re-
quired to have donated or received breast milk in
the previous six months in an arrangement that
was facilitated via the Internet and also to be
proficient reading and writing in English. Adver-
tisements for the study directed individuals who
met the inclusion criteria and who were interested
in participating, to e-mail the study author indi-
cating their desire for further information. In re-
sponse, individuals were e-mailed a letter outlin-
ing the method, background, and purpose of the
study. In this letter those who wished to participate
were instructed to request via e-mail a copy of
the study questionnaire; the request of which was
considered as providing informed consent. In re-
sponse to this request, individuals were e-mailed
a copy of the relevant study questionnaire. Ninety-
one percent of peer milk donors and 87% of peer
milk recipients who requested the study question-
naire completed and returned the questionnaire.
Approval for the study was obtained from the Uni-
versity of Western Sydney Human Research Ethics
Committee.
Peer-to-peer milk donors and recipients were
asked questions relating to their interactions with
milk banks as shown in Table 1. Closed-ended
questions were analyzed using descriptive
statistics and conventional qualitative content
analysis was used to analyze open-ended re-
sponses (Hsieh & Shannon, 2005). Questionnaire
responses were read, reread, and initially coded
to identify recurring categories of response.
Categories that were conceptually similar were
combined, as appropriate. The number of re-
sponses within each category were counted and
http://jognn.awhonn.org
Gribble, K. D.
Table 1: Study Questions for Milk Donors
and Recipients
Milk donors
Have you previously donated milk to a human milk bank?
If yes, where did you donate and why did you not donate to
the milk bank in preference to donating direct to another
mother?
If no, why not?
How important to you is knowing the circumstances of the
need of your milk recipients for breast milk to your
motivation to provide milk?
Milk Recipients
Had you tried any alternatives to internet-facilitated
peer-to-peer donor milk before you obtained donor milk
(e.g., increasing your own milk supply, obtaining milk
from a human milk bank, obtaining donor milk from a
friend or relative, using infant formula)?
If yes, please describe what you had tried and why this
was not sufficient or why you decided not to continue?
responses organized by frequency. The reliability
and trustworthiness of the coding was tested by
providing a description of the coding categories
and a random 20% sample of the responses to
each question to two coders. The percentage of
agreement between these coders was 98%.
Results
Ninety-seven milk donors and 41 milk recipients
from North America, Europe, Oceania, and Asia
participated in the study. Donors ranged in age
from 21 to 43, had from one to four children and
previous breastfeeding experience from 4 to 120
months. The child of the most recent lactation
ranged in age from 0 to 17 months, and donors
had from one to nine recipients. Recipients ranged
in age from 21 to 45, had from one to five children
and previous breastfeeding experience of 0 to 118
months. The age of the recipient child at the time
of first donation ranged from 1 day to 11 months.
Recipients had from 1 to 40 donors from whom
they had received 1.2 L to 300 L. Characteristics
of participants are summarized in Table 2.
A total of six donor respondents had previously
donated to a milk bank, four to a not-for-profit milk
bank and two to a for-profit milk bank. The remain-
ing 88 donor respondents had never donated to a
bank.
JOGNN 2013; Vol. 42, Issue 4
RESEARCH
Donor respondents offered a variety of reasons
for not donating to a milk bank. Many donors ex-
pressed that they lacked opportunity to donate to
a milk bank because there was no local milk bank
or they did not meet milk bank criteria: “There is
no milk bank in New Zealand,” and ‘Due to the
fact that I was on medications (although safe for
breastfeeding) they would not accept my milk.”
Many donor respondents also expressed a view
that the process of donating to a bank was difficult
and that this had dissuaded them from donating to
a milk bank: “I didn’t want to deal with the hassle
of packing/shipping or taking milk to a milk bank.
Also, I didn’t want to have to get blood tests each
time like I’ve read many milk banks ask you to.
It’s time consuming,” and “I would have had to
pump at least 300oz within one month to qualify
to donate.”
Some donor respondents explained that a philo-
sophical objection to milk banking had influenced
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
need.” In addition:
All the tests, rules, and how they treated my
milk put me off. I hated the idea of sending
my milk somewhere and have it treated like
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
sold to another family when it didn’t need
to be.
Finally, some donors described a philosophical at-
traction to aspects of peer-to-peer milk sharing
that contributed to their decision to give their milk
directly to another mother rather than to a milk
bank: “I chose [Eats on Feets] this time because
of the issue of access for mother who would not
qualify for milk bank milk and also the personal
aspect of milk sharing this way.” A summary of
the reasons why donor respondents donated to
a peer rather than to a milk bank is presented in
Table 3.
Almost one half of the respondents (44 individu-
als) did not donate to a milk bank because it was
not possible for them to do so due to their loca-
tion or because milk bank criteria excluded them.
The publicity about shortages of banked milk af-
fected one donor respondent who decided that
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.
Table 3: Reasons Why Donors Had not Donated Their Milk to a Human Milk Bank
Category of response Subcategory
Lack of opportunity No local milk
Did not qualify
Milk bank not accepting more
donors
Was not prescreened
Milk bank did not respond
Milk banking is difficult Viewed the process of
donating as a barrier
Don’t know about milk banks
Didn’t want to ship milk
Philosophical Object to parents having to
objections to milk pay for banked milk
banking
Do not like milk to be
pasteurized
Local milk banks are for profit
Philosophically Prefer to know recipient
attracted to peer
sharing
Wanted to help mothers and
children who would not
qualify for banked milk
JOGNN 2013; Vol. 42, Issue 4
RESEARCH
F Example of response
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).”
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.”
3 “I had enquired into donating to a milk bank and was
told that they were not taking any more donations
due to financial reasons.”
2 “[I had milk in my freezer to donate but] I was told I
would have needed to be prescreened before I
started pumping.”
1 “I wanted to donate milk to a milk bank and attempted
to contact the one closest to me but never got a
response.”
11 “The process is long and tiring. My milk can go to
local mothers much easier.”
7 “There is not very much information easily accessible
about human milk banks.”
4 “I didn’t want to deal with the hassle of
packing/shipping.”
27 “I would not donate to a milk bank because I don’t
support the way they charge exorbitant amounts
of money to families who are obviously in need.”
5 “I like that my milk isn’t fully processed when I share it
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.”
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.”
10 “I think that would be too impersonal for me. I like
knowing who is getting my breastmilk.”
4 “I chose EoF over milk bank this time because of the
issue of access for mothers who would not qualify
for milk bank milk.”
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
for the work of expressing.
premature child or a child with disabilities or
intolerance of formula or a mother who ab-
solutely can’t breastfeed) rather than a child
who would be fine with formula or whole
milk.
Table 4 presents a summary of the rea-
sons why donor respondents felt it was impor-
tant to understand the circumstances of their
recipients.
None of the recipient respondents had used
banked milk. Three recipient respondents had
tried to obtain banked milk but were unsuccessful
because their children did not meet the require-
the cost. Recipient respondents made statements
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
only milk bank in Canada but was not able to ob-
tain milk from them for various reasons (location,
lack of supply, cost).”
Nine respondents rejected attempting to obtain
banked milk because it was inaccessible or be-
cause of the cost: “I knew that we could not afford
milk banks as I had looked into this with my pre-
emie [previous child] and at $4/oz that was way
beyond what we could afford,” and “There is no
local milk bank in our area.” One respondent, a
Malaysian Muslim woman, explained that that she
must know her donors to determine that they were
also Muslim and to take account of the relation-
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
mother has not worked to
maximize her own milk supply
6 “I am not just going to give the milk to just anybody. I want to know that the
mom is having a lot of difficulty producing her own milk or is physically
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
Only a Portion of Lactating Women
Are Potential Milk Bank Donors
Donors in this study were sharing their milk di-
rectly with other mothers, and few had had any
interaction with a human milk bank. One half of
the donor respondents were excluded from do-
nating to a milk bank because they did not qualify
or because there was no local milk bank. This sug-
gests that not all lactating women can be viewed
as potential bank donors. The reasons given by
the remaining donor respondents for failing to do-
nate to a bank suggest modification of the milk
banking process that may assist in bank donor
recruitment.
Reducing the Cost and Process
Disincentive to Milk Donation
Although almost all milk banks are not-for-profit
organizations, the cost imposed by banks on re-
cipient parents in some jurisdictions (e.g., North
America) can be a strong disincentive to women
donating milk to a milk bank. Donor respondents
were affronted by the idea that milk banks could
charge milk recipients a great deal of money for
their gift of milk. Educating potential donors about
the costs of processing banked milk might alle-
viate some of these concerns. In addition, fund-
raising to cover the expenses of recipients who
cannot have the cost of banked milk borne by
their hospital or health insurance might address
this issue. Finally, milk banks could provide infor-
mation on the proportion of their recipients who
have their costs covered by their hospital or insur-
ance so that potential donors can be reassured
that few recipients are paying directly for milk. The
impact of the costs involved in using banked milk
were considered to be a barrier by many peer
donor respondents who had already spent a con-
siderable amount of time expressing milk for dona-
tion. Thus, simplification of the donation process,
for example, local collection depots rather than in-
dividual shipping of milk, could make more milk
available to milk banks.
Providing Information as Motivation
for Donors
Many donor respondents stated that they would
not donate to a milk bank because they preferred
to know the recipient. More than one half stated
that it was important or very important for them to
know why their recipient(s) needed milk. The rea-
sons donor respondents wanted know the circum-
stances surrounding the need for donor milk were
primarily related to ensuring that the need was
genuine or understanding the situation so as to be
motivated to provide milk. Obtaining milk from a
milk bank requires physician assessment of infant
need and so deals with the concern of donors who
simply required that their milk be given to a needy
infant.
This may not be sufficient for donor respondents
who wished to assess whether recipients had
“tried hard enough” to supply their own milk to
their infants. This sentiment, implies an unwilling-
ness to do someone else’s “breastwork” (Bartlett,
2005; Stearns, 2009) if she is capable of doing it
herself. It is also a judgment of the mother’s worthi-
ness, responsibility, or goodness (Murphy, 2000).
Further, some donor responses indicated that they
placed a high value on their milk and wished to
ensure that the recipient(s) would appreciate the
worth of the milk. The value that donors place in

JOGNN 2013; Vol. 42, Issue 4 457

RESEARCH Milk Donors’ and Recipients’ Experiences and Perceptions of Donor Milk Banks
their milk may partially flow from the idea that the
milk is a part of the donor’s self (a concept specif-
ically identified by some donors), and so the gift
of breast milk may be perceived as a gift of the
self. These concerns are unlikely to be able to be
addressed by milk banks.
The absence of feedback to donors about the
need for and outcome of banked donor milk is
a barrier to donation that could be overcome. Pre-
vious research has found that milk bank donors
would like to know more about what happens to
their milk after donation including who receives the
milk, why the milk is needed, and why the infant’s
mother is unable to provide milk (De Alencar &
Seidl, 2010). Milk banks have historically followed
organ donation policy in maintaining anonymity
and not providing donors with information about
how their milk is used. Anonymity in organ do-
nations exists because identification of recipients
might result in feelings of obligation to continue
donations (Warwick, 1997). This constraint may
not apply in milk donation because the milk of an-
other can easily substitute for any individual donor.
Maintenance of anonymity also protects recipients
from claims by donors, whether this is likely to be
an issue in milk donation is unknown. However,
not all institution-facilitated milk banking preserves
anonymity (e.g., Ghaly, 2012; Hsu et al., 2011) and
investigating how such models manage these is-
sues is warranted.
There are logistical difficulties associated with pro-
viding donors with information about the recipients
of their milk. Many milk banks pool donations so
that recipients will receive milk from many donors.
Furthermore, hospitals sometimes order milk from
banks in anticipation of it being required so there
may be some time between donation and use.
Some donor respondents reported that their abil-
ity to express milk was conditional upon knowing
why it was needed because this provided encour-
agement that was necessary for them to be able
to express. In normal circumstances, the demand-
and-supply principle of milk synthesis means that
women are capable of producing milk far in ex-
cess of that required by their infants (Daly, Owens,
& Hartmann, 1993; Kent et al., 2006). However,
motivation is required to engage in and sustain the
work involved in milk expression. Milk expression
has been identified as demanding, tedious, and
stressful, requiring commitment and sacrifice over
a protracted period (Avishai, 2007; Stearns, 2009).
As such donors are not only donating their milk,
but also their time and work and the investment
458 JOGNN, 42, 451-461; 2013. DOI: 10.1111/1552-6909.12220
required of them is large. No payment is made for
donated milk but the milk is donated with a cost
to donor and their families; breast milk can only
be considered to be free if the value of women’s
labor is ignored (Shaw, 2010). Although none of
the donor respondents desired payment for their
work or milk, there is the sense that information
about their recipient’s need for their milk consti-
tutes a reward for their work that facilitates milk
donation.
Thus, providing milk bank donors with greater in-
formation could make more banked donor milk
available by providing donors with motivation to
donate milk. This would increase the number of
women able to donate and/or increase the length
of time for which donors continue to donate. In-
formation may also be considered a type of reci-
procity that acknowledges the effort and giving
of self that is involved in milk donation (Shaw,
2010). Donors may not require identifying infor-
mation to donate to milk banks but simply greater
knowledge of the need for or the use of their
milk. As demonstrated by the donor respondent
who changed her mind about donating to a bank
after hearing of shortages, even basic informa-
tion demonstrating the need for milk can change
practice.
Referring Parents of Healthy Infants
to Milk Banks Is not Helpful
Recipient respondents had had very limited con-
tact with milk banks, and none of them had been
able to obtain banked donor milk. The infants of
recipient respondents were generally healthy and
without complex medical problems and so did
not meet the criteria usually necessary to qual-
ify for banked donor milk. For the recipient re-
spondents who were unable to provide their own
breast milk the choice of supplementary milk was
infant formula or human milk donated by a peer.
Should these experiences be typical, statements
by health authorities that those needing additional
human milk for their infants obtain it from a milk
bank are not helpful at best and disingenuous at
worst. It does not assist families in need of milk
for their children to be directed to milk banks that
cannot supply them with milk, nor does it assist
milk banks to be inundated with requests for milk
that they cannot supply.
Identification of Milk Donors Provides
Safety to Islamic Milk Recipients
One recipient respondent expressed a religious
imperative to know her donors. Although her view
http://jognn.awhonn.org
Gribble, K. D.
was singular among the recipients in this study,
there is reason to believe that it may be an opinion
that is widespread in Muslim countries. Breast milk
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
woman and child and care must be taken to
avoid consanguineous marriages (Parkes, 2001).
Some Muslims consider that the feeding of banked
donor milk to hospitalized infants does not create
a milk kinship relationship (Ghaly, 2012). However,
no Muslim country has a traditional milk bank (El-
Khuffash & Unger, 2012). Although traditional milk
banking may be unacceptable to many Muslims,
changes in the process may make it permissible.
The Duchess of Kent Hospital in Malaysia and
Adan Hospital in Kuwait provide a modified milk-
banking process in their NICUs whereby milk is
not pooled and donor and recipient are introduced
to one another (Ghaly, 2012; Hsu et al., 2011).
This is effectively a regulated form of peer-to-peer
milk sharing. The issue of milk kinship is another
reason for milk banks (especially those in areas
with a large Muslim population) to consider allow-
ing for greater transparency in the milk banking
process.
Peer-to-Peer Donors and Recipients and
Milk Bank Donors and Recipients Are
Recruited from Different Pools
Women have always shared milk with one another,
but the scale of the online milk-sharing networks
has led to fears that this new form of milk sharing
is jeopardizing the infants served by milk banks.
However, concerns about shortages of banked
milk have only been expressed in North Amer-
ica. Data on the amount of milk donated to milk
banks in North America is not available, but ac-
cording to the Human Milk Banking Association of
North America the amount of milk dispensed by
member milk banks has steadily increased from
1.2 million ounces in 2007 to 2.2 million ounces in
2011 (Personal communication, Jean Drulia, Pres-
ident Human Milk Banking Association of North
America, May 16, 2012). Thus, it seems that milk
shortages may be more a result of increased de-
mand rather than a decreased supply. Extensive
publicity about peer-to-peer milk sharing includ-
ing associated discussion about milk banks may
have increased awareness of banked milk and so
increased the demand for banked milk (the Fac-
tiva database yielded 122 articles in print media
including the names Human Milk 4 Human Babies
JOGNN 2013; Vol. 42, Issue 4
RESEARCH
Milk donated via peer sharing may be sourced largely from a
different pool of donors from that of milk banks.
and Eats on Feets). Furthermore, the U.S. surgeon
general’s appeal to make banked donor milk avail-
able to more infants in NICUs, may have increased
the demand (U.S. Department of Health and Hu-
man Services; 2011). Regardless of the reason,
the continuing growth in the need for banked
donor milk requires an increased supply of donors
and their milk.
Thus far, peer-to-peer milk-sharing networks ap-
pear to have been viewed as a threat to traditional
milk banks as a competitor for the scarce resource
of donors and their milk. The data from this study
suggests a different possibility, that the milk being
donated via peer-to-peer sharing is predominantly
sourced from a different pool of donors than that
of milk banks. It seems that a large proportion of
women who donate to a peer are excluded from
donating to a milk bank because of their location
or personal characteristics. Furthermore, it seems
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
of this information is a barrier to donation to a milk
bank. However, there is a possibility that some of
this latter group of donors might be able to be re-
cruited to milk banks with modification of the milk
banking process. It is also possible that peer-to-
peer milk sharing is decreasing the demand on
milk banks from the population of relatively well
infants served by milk sharing.
The conclusions that can be drawn from this study
are limited by the use of convenience sample of
donors and though care was taken to recruit as
diverse as sample as possible, it is unknown how
representative their views and experiences are of
the population of individuals involved in peer-to-
peer milk sharing. A further limitation of this study
was that it required respondents to be sufficiently
proficient in English to be able to complete the
study questionnaire. This likely limited the partici-
pation of donors and recipients in countries where
languages other than English predominate. Fur-
ther research should be undertaken in languages
other than English, in particular to explore milk
sharing in Islamic countries where, as noted, the
belief in milk kinship impedes the development of
traditional milk banking.
459
RESEARCH Milk Donors’ and Recipients’ Experiences and Perceptions of Donor Milk Banks
Implications for Practice
Despite concerns about the safety of peer-to-peer
milk sharing and its potential impact upon milk
banks, it is likely that Internet-based milk-sharing
networks will continue to operate. With this in mind,
cooperation should be encouraged between milk
banks and peer-to-peer milk-sharing networks.
Peer-to-peer milk-sharing networks would bene-
fit from the expertise and guidance of milk banks
in ensuring that milk is shared as safely as possi-
ble. Milk banks would benefit from the experiences
of peer-to-peer milk-sharing networks in support-
ing lactating women to engage in the work of ex-
pressing milk for donation. Peer-to-peer networks
could also act as a conduit encouraging women
who are suitable and able to donate milk to a milk
bank to consider doing so. Health professionals
should not direct parents in need of human milk
for their infant to milk banks unless obtaining milk
from such banks is a realistic possibility. Where
banked donor milk is unavailable, health profes-
sionals should provide parents with evidenced-
based information about the risks and benefits
of other feeding options in order to enable in-
formed decision-making (Gribble, 2012; Gribble &
Hausman, 2012).
Conclusion
Concerns have been raised that milk banks and
peer-to-peer milk-sharing networks are in com-
petition with one another. However, it appears
that peer-to-peer milk sharing and milk banking
may largely involve different groups of women
and infants. With greater transparency in the milk-
banking process some peer sharing donors may
choose instead to donate to a milk bank. Cooper-
ation between milk banks and peer-to-peer milk-
sharing networks could benefit both groups.
Acknowledgement
The author acknowledges Professor Virginia
Schmied, Dr. Kathleen Kendall-Tackett, and the
anonymous reviewers who provided helpful com-
mentary and suggestions.
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