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A Descriptive Study of the Attitudes, Perceptions, and Experiences of Human Milk Donation

Wambach, Karen PhD, RN, IBCLC, FILCA, FAAN; Bateson, Tiffany MSN, RN-BC; Matheny, Paige BSN, RN; Easter-Brown, Kristan BSN, RN, IBCLC

Section Editor(s): Parker, Leslie A.

doi: 10.1097/ANC.0000000000000659
Human Milk Science: Special Series
Free
SDC

Background: The use of pasteurized human donor milk has increased in recent years due to health benefits and rising number of infants who need pasteurized human donor milk. Little is known about milk donors' experiences or what contributes to their motivation to donate.

Purpose: Using existing evidence and the theory of planned behavior as a guide, our purpose was to describe the personal and social aspects of mothers' milk donation to a milk bank in the Midwest United States.

Methods: A convenience sample of 50 current human milk donors enrolled in this cross-sectional descriptive study. The investigator-designed online survey consisted of open and closed questions based upon existing evidence and theory of planned behavior for assessing reasons for donation, beliefs about benefits and barriers, social support for donation, donation history, and current experiences. We used the Iowa Infant Feeding Attitude Survey to characterize general breastfeeding attitudes. Data analysis consisted of content analysis for narrative data and descriptive statistics for continuous and dichotomous variables.

Findings/Results: Six themes represented experiences of discovering donation, reasons and motivations for donating, benefits and barriers to donation, confidence in donating, and support for donation. Practical and altruistic motivations for donation were prevalent. Confidence for donation was instilled by adequate milk supply, growth of the infant, and the milk bank process and professionalism. Support from others was universal.

Implications for Practice: Findings can inform education regarding human milk donation. Human milk banks may benefit from identified donation barriers to improve support for donors.

Implications for Research: Findings are being used for instrument development for research regarding women's intentions and donor behavior.

University of Kansas School of Nursing, Kansas City (Dr Wambach); Verity Health System, Los Angeles, California (Ms Bateson); Overland Park Regional Medical Center, Overland Park, Kansas City, Kansas (Ms Matheny); and Heart of America Milk Bank, St Luke's Health System, Kansas City, Missouri (Ms Easter).

Correspondence: Karen Wambach, PhD, RN, IBCLC, FILCA, FAAN, University of Kansas School of Nursing, Mailstop 4043, 3901 Rainbow Blvd, Kansas City, KS 66160 (kwambach@kumc.edu).

This work was supported in part by a grant from University of Kansas School of Nursing, Office of Grants and Research, Faculty Research Award.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org).

Mother's own milk provides the optimal nutrition and immunologic protection for human infants. Exclusive breastfeeding is recommended for the first 6 months of life, and human milk with appropriate complementary foods is recommended until the end of the first year of life and beyond.1 In situations in which mother's own milk is not available or is not adequate in amount for the infant, pasteurized human donor milk (PHDM) is recommended.1 Research demonstrates that not providing PHDM or PHDM as part of a human milk–based diet puts premature or low birth-weight infants at risk for such conditions as necrotizing enterocolitis,2 sepsis,3 and bronchopulmonary dysplasia.4 Consequently, and in combination with the rising number of premature births, the use of PHDM has increased exponentially in the last 20 years. Rates of PHDM use in the United States in the specialty care of sick and/or premature infants are reported at 22%5 to approximately 30% in 2011,6 with increases up to approximately 59% in 2014.7

Human milk banks exist to collect, process, screen, store, and distribute PHDM to infants for whom donor human milk is prescribed by a licensed healthcare provider.5 The Human Milk Banking Association of North America (HMBANA) and other like organizations around the world (eg, European Milk Bank Association) have set standards for donor milk banking operations. “HMBANA advances the field of nonprofit milk banking through member accreditation, development of evidence-based best practices, and advocacy of breastfeeding and human lactation to ensure an ethically sourced and equitably distributed supply of donor human milk.”8 Lactating mothers who have excess milk,9,10 or in some cases bereaved mothers,11,12 donate to human milk banks.

Currently, there are 27 HMBANA-accredited nonprofit milk banks in the United States and Canada that are wholly dependent on donated milk.13 In 2018, HMBANA reported that 6.5 million ounces of human milk were donated by 11,672 mothers; 5 million ounces of milk went to hospital neonatal intensive care units (NICUs) and 1.5 million ounces went to infants at home.14 Although human milk donations have increased each year, the demand for donor milk likely exceeds the current supply.15 Therefore, understanding women's experiences and reasons to donate their milk to human milk banks is important because that knowledge could help design education for potential donors. A synthesis of current evidence regarding milk donors in the following text provides rationale for this descriptive study of experiences of women who donate their milk to a human milk bank.

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CURRENT EVIDENCE ON DONORS AND EXPERIENCES OF DONATING

Donor Characteristics

Many similarities exist among mothers who choose to donate their milk. Examining the personal characteristics of human milk donors can provide evidence on who is more likely to decide to donate milk. Data described included women's age, location, occupation, level of education, and relationship status. Common characteristics of donors across research conducted mostly in Brazil include stable couple relationships and higher education status10,16,17 and sometimes, women of higher parity.17 Similarly, 1 American study showed that most donors were married, well educated, and financially secure, with reported healthy dietary intake, alcohol use, and exercise.18 These American researchers also found that donors were often blood or plasma donors, suggesting an altruistic factor. Fonseca-Machado et al10 studied Brazilian milk donors and, like the American study, found that donors generally practiced healthy behaviors such as obtaining prenatal care.

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Reasons for Donation

Milk donors have various individual reasons for donating their milk; however, a common reason for a large percentage of milk donors is excess milk production. This was common across different countries including Brazil,10,19 France,9 and the United States18 (second highest reason for donating). Another reported reason was more philanthropic in nature. Many of the studies, across Brazil, France, and the United States, reported that mothers wanted to help other mothers and infants citing concepts such as altruism,10 a general desire to help others,9(p201) and giving back.18,20 Thomaz et al,17 in Brazil, reported that the most common reason for donation was the “encouragement of health professionals,” followed by “the needs of the babies the banks serve.”(p71) Notably, Brazil has the largest number of milk banks in the world, and donor milk banking is integrated into federal, state, and local promotion, protection, and support efforts.5

Finally, Welborn,12 using phenomenology, described how donating human milk can help women grieve after a perinatal loss by making them feel like mothers and like they were helping other infants. Similarly, Cole and team11 examined the experiences of 2 mothers whose infants received perinatal palliative care and then continued to lactate and donate their milk after their infants died. These women each experienced different situations surrounding their infants, but both felt that the expression and donation process helped them through the grieving process by not discarding “such an invaluable resource”(p568) or maintaining a “longer connection”(p569) to the deceased infant.

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What This Study Adds
  • Descriptive information on the personal and demographic characteristics of women who donate their milk to a Midwest US milk bank certified by the Human Milk Banking Association of North America (HMBANA).
  • Evidence on what motivates women to donate their milk to a human milk bank.
  • Description of benefits and barriers to human milk donation, factors contributing to confidence in donation, and sources and types of support for human milk donation.
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Reason for Not Donating in Previous Children

In some milk donation studies, donors gave reasons for not donating their milk with previous children. Fonseca-Machado et al10 found that among the multiparous mothers in their study, 66.7% did not donate previously. Alencar and Seidl19 found that 41.7% of their sample had not donated previously because of embarrassment, lack of knowledge of the donation option, lack of information at the hospital, lack of milk, and lack of personal initiative. Related Australian research by Mackenzi et al21 examined mothers' knowledge of human milk banking and their attitudes toward it. They found that many mothers did not understand the donation process and thought it was too difficult. Some mothers expressed concerns about not being able to meet the needs of their own child.

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Support for Donation

Only Brazilian researchers have studied personal and institutional support networks and their influence on initiation and continuation of milk donation. Fonseca-Machado et al10 reported that more than 64% of their sample reported receiving support from their family, partner, or friends, or a combination of those supports. Alencar and Seid19 reported that about 19% of women reported the emotional influence of important people as essential in their motivation to donate, paired with the support of the hospital in implementing donation after deciding to donate.

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Summary and Purpose

In summary, researchers have examined the demographics and personal characteristics of donors, the reasons for donating and not donating, and the role of personal and institutional support for donation. However, little information is available surrounding the behavioral experiences of donation, the feelings/emotions toward donation, and support received by donors, especially in the United States. Therefore, evidence is needed to describe personal, social, and cultural beliefs regarding human milk donation to better understand donor motivations and behaviors and ultimately influence potential donors.

The purpose of this study was to explore and describe the experiences of mothers who donated their milk to a Midwest US HMBANA-certified milk bank. A secondary purpose was to determine general maternal attitudes to breastfeeding, so as to examine milk donation behavior in the context of general attitudes to breastfeeding. The long-term goals of the research are 2-fold: (1) to develop a research tool to measure facets of human milk donation behavior based in the theory of planned behavior (TPB)22; and (2) to contribute to the development of theory-based interventions to promote and support milk donation among lactating women.

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Research Questions and Theoretical Framework

  1. What reasons and motivations lead women to donate their own “mother's milk” to a milk bank?
  2. What are women's perceptions of the benefits and barriers to donating their own “mother's milk” to a milk bank?
  3. How do donors' partners and families support milk donation?
  4. What factors contribute to women's confidence in their ability to donate their own “mother's milk” to a milk bank?
  5. What are the general breastfeeding attitudes of mothers who donate their milk?

Central to the TPB23 is the proposition that individuals form intentions to carry out behaviors that they believe will result in valued outcomes. Behavioral beliefs about outcomes undergird personal attitudes to the behavior. In addition, social referents' views about the target behavior (normative beliefs) and personal control factors (control beliefs) inform the development of subjective norms and perceived behavioral control. Attitudes, subjective norms, and perceived behavioral control are predictive of the formation of behavioral intentions. Behavioral intention, a proxy for how willing one is to try the behavior, is the immediate antecedent to behavioral performance. These concepts (attitudes, subjective norms, perceived behavioral control, and intentions) and posited relationships have been supported in many previous studies of breastfeeding.23–25 Human milk donation is a very specific behavior of lactating women, going beyond nourishing the individual infants of these mothers. Current evidence on milk donation appears to be consistent with the concepts of the TPB. Therefore, the questions to be used for data collection were designed to tap into women's behavioral beliefs, normative beliefs, control beliefs, intentions, and actual behavioral experiences.

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METHODS

Design

We used a descriptive cross-sectional design to conduct the study using secure-encrypted online data collection (eg, REDCap; https://www.project-redcap.org/). This report focuses on discovering reasons and motivations for donating, benefits and barriers to donation, confidence in donating, support for donation, and general attitudes about infant feeding.

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Setting and Participants

A convenience sample of 50 women who were current or past milk donors within the last year at a regional HMBANA milk bank participated. Participants were English speaking and able to read and write. The milk bank director and staff supported study recruitment by identifying potential participants from their roster of new, current, or past donors via e-mail, telephone, or in-person contact (eg, during screening processes or during milk drop-off). A standard information sheet described the study purpose and requirements. The study team then followed-up, by telephone, women who expressed interest in participating. Additional study information was shared and if the woman agreed to participate, the link to the online survey was provided. Informed consent information was provided with the online survey and actual participation implied study consent. The study was approved by the institutional review boards of Saint Luke's Health System and the University of Kansas Medical Center.

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Measures and Instruments

Based in the current literature on human milk donation experiences and donor characteristics, and the concepts of the TPB, the investigators developed a 26-item survey composed of closed and open-ended questions. The first author, who has extensive knowledge on research measurement and the TPB, and who has done several studies using the TPB, initially developed the 26 survey items. Additional information from Ajzen26 on TPB survey development was used to guide the survey item development. The study second author also contributed to the item development process, basing her review and edits on the current evidence on milk donation and TPB concept definitions. Table 1 illustrates the definitions of the concepts of the TPB and example items from the Experience of Human Milk Donation Online Survey; the entire survey is available in Supplemental Digital Content, available at: http://links.lww.com/ANC/A50.

TABLE 1

TABLE 1

In addition, we surveyed participants on their general attitudes toward breastfeeding/infant feeding using the Iowa Infant Feeding Attitude Scale (IIFAS)27 to provide sample description and context to the study results. The IIFAS was developed to measure maternal attitudes toward infant feeding methods; it includes 17 items with responses on a 5-point Likert/agreement scale (possible score range of 17-85). Items on the scale fit in the areas of benefits and disadvantages of breastfeeding and formula related to infant health and emotional, lifestyle, and convenience factors.

Psychometrics of the measure were supported in development studies as well as more recent studies in various cultural groups.27–29 Cronbach α for the current study was adequate at 0.84. Demographic information (age, parity, income, education, income, employment status) and questions regarding breastfeeding education and knowledge and past blood donation were solicited to characterize the sample.

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Data Analysis

Descriptive statistics (frequencies, percentages, means, medians, standard deviation, range) were used to characterize the sample demographics and other information on the donation experience. Descriptive statistics were used to characterize the scale results to reflect degree of positive attitudes to breastfeeding.

Using principles of content analysis,30 narrative text data from the survey open-ended questions were analyzed by examining words and phrases to formulate categories and themes relative to donor perceptions and descriptions of their experiences. In addition, TPB provided the framework within which the data were examined.22 The data were read repeatedly to develop and characterize participants' description of behavioral beliefs (reasons, motivation, and potential outcomes of donating milk), normative beliefs (views and support from family, etc), control beliefs in this study (confidence in the ability to donate and sources of confidence/not confidence), and donor intentions. Categories representing these beliefs were developed and themes elucidated.

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RESULTS

Sample Description

Our sample of 50 current milk donors had the following characteristics: majority white, married, college educated, employed outside the home, most with incomes greater than $70,000 annually, and a mean age of 30.8 years (see Table 2). These women began donating their milk between 10 days and 14 months after the birth of their infants; most began donation between 3 and 6 months. The majority were first-time donors with the current infant, while 5 women had donated with 1 other child. Most women intended to donate their milk until their infant reached 1 year of age, the limit for donating milk to HMBANA-certified milk banks. At the time of the survey, most women (n = 43) had donated once, with the remainder giving twice (n = 3) or 3 times (n = 2); 2 women also had milk shared in the past, that is, informal milk sharing—directly shared their expressed milk with other mothers of infants in need.31 Frequency of planned or continued donation variedly widely from “sporadically” to regularly every 1 to 3 months to when the “freezer was full.” Single donation amounts ranged from 50 (after the required first 150-oz donation) to 2200 oz, with most between 200 and 300 oz. Sixty-two percent of our sample had donated blood in the past and 4 (13%) of those considered themselves regular blood donors.

TABLE 2

TABLE 2

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Mothers' Experiences of Donation

The content analysis of survey results resulted in 6 themes about discovering donation, the reasons and motivation to donate, the benefits of and barriers to donation, confidence in donation, and support for donation. Each theme, constituent categories, and example narrative are presented in Table 3.

TABLE 3

TABLE 3

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Theme 1: Discovering Donation: The Why and How

Milk donation was discovered in various ways and for different reasons. Often, milk expression and donation were a remedy to a breastfeeding problem or individual feeding situation. Women discovered donation through their social support networks, healthcare providers, independent research, or knew about milk donation because they were healthcare workers themselves. About 34% of our donors received information or recommendations to donate from nurses, lactation consultants, pediatricians, and social workers.

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Theme 2: Motivation to Become a Milk Donor Is Practical and Altruistic (Behavioral Beliefs)

When women were asked about specific reasons for donating, they described their experiences as rooted in practical problem solving, for example, they donated because of oversupply, or needed to free up space in their freezers, or they did not want to waste their milk, which they had worked hard to produce and express. They were also very focused on helping other families, mothers, and infants. Often, both the practical and the altruistic elements were synergized in the motivation to donate.

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Theme 3: Benefits and Outcomes of Milk Donation Are Personal and Social (Behavioral Beliefs)

Women described the benefits and outcomes of milk donation as personal and social in nature or both. Women spoke of personally feeling better due to milk donation (eg, a bereaved woman), it was easy to do, they felt like the time spent in collecting their milk was not wasted, there were health benefits to themselves, their milk was not wasted, and freezer space was freed up. At the same time, those personal benefits also provided benefits to other families and infants.

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Theme 4: Barriers to Milk Donation Are Few and Logistical/Economical (Behavioral Beliefs)

Nearly 40% of the sample cited no barriers to milk donation. Barriers represented in this theme were related to process of expression and donation (eg, making sure your own infant had enough first, managing other children, lack of knowledge of donation, parting with milk that you worked hard for), dealing with milk donation rules and restrictions (eg, blood draws, time limit of the 1-year birthday of the infant, minimum amount of donation, exclusion due to medication, keeping track of expiration dates of milk), and costs and travel distance to donation (eg, travel expense, finding and purchasing dry ice, cost of collection containers, cost to the recipients, limited donation places).

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Theme 5: Confidence in Ability to Donate Is Dependent on Milk Supply, Infant's Growth, and Milk Bank Processes (Control Beliefs)

Women built and maintained their confidence in their ability to donate their milk based upon adequate milk production, witnessing their own infant's growth, and observing the donation process and expertise of the milk bank staff. Women described their confidence in ways like this: “I feel very confident donating my milk. I am a healthy, fairly young mother, and my son is growing very well, so I know that my milk is providing him all the nutrients he needs to thrive and grow.” In addition, our donors spoke about the rigorous quality control processes at the milk bank and information and support offered to them as helping their confidence.

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Theme 6: Support for Milk Donation (Normative Beliefs)

Our participants reported that they felt supported by their husbands, family, and friends. They perceived that the support came in the form of encouragement, instrumental/physical support in freezing and packing the milk, and tending to the infant during expressing. Participants reported that their families and husbands voiced their pride in their efforts to donate and help other families, and consequently many joined in to assist and become part of the process. However, our participants also reported that some fathers had concerns about there being enough milk for their own infant, and some needed information and education about the process and purpose of milk donation. No mothers reported feeling unsupported.

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General Breastfeeding Attitudes and Knowledge of Donors

Results from the IIFAS demonstrated that the sample had overall positive attitudes toward breastfeeding. Total scores on the scale ranged from 47 to 85 out of a possible 17 to 85; the lowest score was above the midpoint of the scale range and the mean score was 69 (SD = 7.95), both indicative of positive attitudes. Finally, most of our donors felt that they were knowledgeable about milk donation (n = 48; 96%).

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DISCUSSION

Our sample of milk donors in Midwest United States mirrors other research findings on demographic and personal characteristics of donors internationally and nationally.10,16–18 Milk donors were married, well educated, mature in age, and economically advantaged. The results from the IIFAS and knowledge survey item demonstrated that our donors held strong positive attitudes about breastfeeding and considered themselves “knowledgeable enough” about milk donation. This descriptive information about our sample is useful in interpreting our study findings.

Our findings of how women discovered donation are consistent with previous research on women's experiences donating their milk.9,10,17–19 Our donors often found out about milk banking from a healthcare professional when they had an excess amount of milk. Milk banks rely on women who may experience ample or oversupply of milk, or women who may be regularly accumulating small amounts of milk that result in a large stockpile over months.32 Our findings suggest that it is important that healthcare providers recognize when women are experiencing abundant milk supply and provide information about milk donation as an option, so that these women may donate their milk if they choose to do so.

Our second theme reflected the majority of responses that the motivation to become a milk donor is often practical in nature and altruistic. Again, many of the donors in our sample had an oversupply of milk and many did not want to see their extra milk go to waste and wanted to help others. These findings are consistent with previous research on women's motivations to donate their milk due to oversupply9,10,18,19 across countries. Altruism was also common among donors sampled in other studies.9,10,18,20 Reflecting on our sample's positive attitudes toward breastfeeding, as found with the IIFS, it could be speculated that positive beliefs about breastfeeding and human milk among our sample compelled them to donate their unused milk to help those in need. Future prospective research regarding the relationship of attitudes and knowledge regarding breastfeeding and intended and actual milk donation is needed.

By understanding women's motivations to donate and applying those to development of strategies to promote milk donation, it is possible that the proportion of lactating women who donate their milk could be increased. Stevens and Keim33 highlighted 6 possible strategies to increase human milk donation. Two of their strategies apply to our findings. Strategy 2, “emphasizing similarities between potential donors and potential beneficiaries,”(p345) is reflective of when 1 participant spoke about understanding that she may need to use donor milk in the future for future children, and that she donated because she would like others to donate to her if she were the one in need. Strategy 4, “use negative arousal to promote donations,”(p345) may also be effective in increasing donations among women because many of the women spoke about wanting to help the sick, NICU infants. This may especially be effective, because Stevens and Keim32 argued that this strategy works best if the “intended recipient of the assistance is viewed as blameless for his or her circumstances,”(p345) which is the case for infants who end up in the NICU. Increasing donations could help balance the supply and demand for donor milk and allow more infants to benefit from human milk who are otherwise unable to do so.

Benefits, or outcomes, that women saw in milk donation were personal and social. Again, our results are consistent with previous research. For example, Welborn12 and Cole et al11 found that donating human milk can be an effective way to assist in the grieving process for women who have lost an infant; this rang true for our participant who had lost her infant. In addition, other researchers17,20 found that women felt a strong sense of satisfaction and pride from helping infants and families through donor milk. This is similar to our participants' experiences as the majority felt that a benefit to donating was to help families in need, and many expressed that it felt good to help others. Women and families who have given birth to a premature infant can benefit from information and education on human milk donation for their own infants and hopefully planting the seed for their future as a donor.

Other than the lack of knowledge of milk banking, there is very little previous research about barriers women find to donating their milk.10 In our sample, many women identified no barriers; however, there were a number of participants who found the time it took to get to the milk bank or the distance they needed to travel was a barrier to the donation process. A suggestion for improvement by one of our participants was to have area hospitals accept milk donations and have the hospitals properly store and transport the milk to the milk bank. This concept of a holding space is not new. Milk depots, most often associated with a hospital, hold donated frozen milk and transport it to milk banks for processing. However, those depots are generally more regionally located, which may not meet the needs of donors from rural or distant locations. Some of our participants identified other barriers, such as the cost of the collection bags or finding dry ice for transport. This issue may be addressed by milk banks providing donors with these supplies. Conversely, some of the other barriers identified, such as needing to get blood drawn, cannot change because the blood is drawn to ensure the safety of the donor's milk.

Our sample of donors readily identified common factors that contributed to their confidence in their ability to be a milk donor. Factors promoting confidence included milk production adequacy, infant growth and health, and trust in the systematic rigorous milk banking processes for a safe donor milk product. Little research evidence exists about donor confidence although some evidence exists that donors' past donation experiences influence current donor behavior.33

Our findings regarding the receipt of support from husbands, family, and friends for milk donation are consistent with research from Brazil describing personal support systems for milk donors.10,19 Although, associated with the survey item related to factors impacting confidence, information from the milk bank was also described as supportive to some participants. This finding is consistent with the findings of Candelaria and colleagues,20 who found that NICU staff supported mothers donating milk in a hospital-based milk bank. Milk bank support also reflects the subjective norm concept of the TPB22 and demonstrates the importance of social support for personal behaviors.

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Limitations and Strengths

Limitations of this study include the use of a convenience sample from 1 regional milk bank, which may limit the generalizability of findings to other geographic locations in the United States. Furthermore, our sample's strong positive attitudes toward breastfeeding and adequate knowledge of human milk donation may not be reflective of the general population of potential milk donors. In fact, the positive attitudes and knowledge of this sample of milk donors may very well be an important antecedent to donor behavior, much like breastfeeding attitudes impact breastfeeding intentions and behaviors as often seen in TPB breastfeeding research.26

A second limitation of our methods may be the use of an online survey instead of individual interviews; the responses to the survey may lack rich and in-depth data in comparison to in-person interviews in which women could go into more depth because they do not have to write out their responses and the interviewers could probe for more in-depth responses. However, as noted in our example narratives, many participants gave lengthy responses to the survey questions. We also had the option and received permission from participants to use follow-up phone calls to collect additional data for clarification/amplification as needed. We found that additional data collection was, in fact, not needed, indicating that the survey items elicited adequate depth of information. The online surveying was chosen for convenient data collection and was well received, as evidenced by no missing data or survey discontinuation. Furthermore, all women who were invited to the study took part.

Finally, another limitation to the survey development process was that a separate content validity process was not done for this theory-based survey and the survey was not piloted prior to data collection. Again, our complete data, as noted, indicate that survey questions were clear in meaning and our depth of responses could indicate the relevance of the items to the phenomenon of human milk donation behavior. Finally, we believe that a major strength of our study is that it is one of a very few US-based studies of human milk donation.

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CONCLUSION

Overall, the results from this Midwestern US sample were consistent with previous studies done internationally and in the United States on women's experiences donating their milk. By identifying the most common ways women discovered milk donation, such as through healthcare professionals, new policies can be introduced into healthcare settings for patient education. More information about milk donation as an option for women, and given by healthcare providers, including nurses, lactation consultants, obstetricians, and pediatricians, may be very helpful in increasing women's knowledge of milk donation and consequently increasing the number of women who choose to donate.

Major motivators for these women to donate are altruism, wanting to help sick, premature infants, and not wanting to waste previously expressed milk. By tapping into these motivations while providing patient education or community outreach, it is possible that the proportion of lactating women who donate their milk will be increased. Although many women identified no barriers to donating their milk, the barriers that were identified could be addressed to increase donations. Barriers identified by this study may be used to enhance milk bank practices to support donors, such as providing necessary supplies for safely transporting milk, and perhaps finding ways to assist donors with transportation. Our research adds to the evidence base related to human milk donation and potentially improving education, support, and promotion of human milk donation.

Finally, the TPB22 guided development of the Experience of Human Milk Donation Online Survey. Our qualitative findings will be used to develop items for a TPB-based measure of human milk donation. Items based in behavioral, normative, and control beliefs will be developed, which will ultimately lead to a measure that could be used in educational intervention studies focused on promoting milk donation.

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Keywords:

human milk donation; lactation; milk banks; pasteurized human donor milk; theory of planned behavior

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