Impact Ethics

Milk

With increasing recognition of the short-and long-term clinical benefits of human milk, and economic, social and clinical barriers to breastfeeding success, demand for donated milk is rising steadily. The World Health Organization recommends using pasteurized human donor milk as a first food for newborns when a parent’s own milk is unavailable for social or clinical reasons. This is particularly important for the preterm population who are at risk of serious complications from gut infections.

Human milk has always been shared among families; wet-nursing is a global and ancient practice. Human milk banks emerged about 100 years ago. At present, both non-profit and for-profit banks exist in North America; for-profit banks can and do compensate “donors” financially whereas non-profit banks only reimburse donor expenses, such as the cost of shipping or of materials including storage bags and cooler gel packs. With the rise of social media, peer-to-peer milk sharing is increasingly commonplace. Peer milk sharing Facebook sites such as Eats on Feets and Human Milk 4 Human Babies facilitate connections between donors and recipients and discourage payment. Milk shared between peers is generally unpasteurized. Human milk may also be purchased online, through private classifieds (usually unpasteurized) or through companies (pasteurized).

Four non-profit milk banks operate in Canada: the Public Mother’s Milk Bank operated by Héma-Québec in Montreal; the Rogers Hixon Ontario Human Donor Milk Bank in Toronto; the Northern Star Mother’s Milk Bank in Calgary; and the BC Women’s Provincial Milk Bank in Vancouver. The Human Milk Banking Association of North America (HMBANA) governs how non-profit milk banks operate. In distributing milk, HMBANA member banks must prioritize the most fragile infants in neonatal intensive care units (NICU) as recipients. Although there is no milk bank east of Quebec, hospitals in New Brunswick, Nova Scotia and Newfoundland purchase milk from the banks in Calgary and Toronto.

HMBANA-member banks must conduct rigorous screening of donors for potentially risky behaviours, similar to blood donation screening. Donors are required to provide negative blood test results for HIV, hepatitis and syphilis. Donation must be approved by the donor’s health care practitioner. After pasteurization, donations are tested for any remaining contamination.  HMBANA banks teach safe milk handling and re-educate donors if bacterial cultures are present after pasteurization.

Milk distributed by banks is subject to the Canada Food and Drug Act. Section 4 prohibits sale of food that is harmful, unfit for human consumption, adulterated, or prepared in unsanitary conditions.  Banks are subject to inspection to monitor compliance.

The first organized milk bank opened in Vienna, Austria, in 1909. The first milk bank in North America opened in 1919 in Boston. Milk banking grew steadily throughout the 20th century: in the 1980’s there were 23 milk banks in Canada. During the HIV/AIDS crisis in the 1980’s , fears of transmission through breastmilk resulted in all of these banks closing, except for the BC Women’s Provincial milk bank, which has been open continuously since 1974. Nowadays donors have serology testing for HIV as well as other blood-borne infections.

Four milk banks now operate in Canada. Organized web-based milk sharing in North America began in about 2010 with the emergence of Facebook for platforms.

Because the HMBANA banks have operating expenditures, staff, and overhead, they charge approximately $4.50/ounce for pasteurized human donor milk. Milk that is provided in-hospital is prescribed and is covered by Medicare like all medications provided to patients while in hospital. Outside of hospital, no private insurer currently covers the cost of donor milk. This is because pasteurized human donor milk does not have a Drug Identification Number (issued by the Therapeutic Products Directorate of Health Canada) and required to be considered for third-party insurance coverage. Eligibility for a prescription for pasteurized human donor milk is determined by clinical and administrative considerations.  For example, a hospital may have a policy that all infants born under 1800 grams or under 34 weeks gestation will be prescribed donor milk with parent/guardian consent to treat.

There are concerns that the cost of pasteurized milk limits its availability. Some suggest remunerating donors as an approach to increase donation.

HMBANA prohibits non-profit member banks from remunerating donors (for example, by the ounce), but allows reimbursement of actual expenses such as shipping costs. There is concern that payment for milk may result in the exploitation of marginalized populations; impact quality by creating an incentive to water milk down; compromise safety in milk handling resulting in microbial contamination; affect donor disclosure about health status; and impact the donors’ other children because milk is sold that otherwise would be available to them.

For-profit human milk companies market products such as shelf-stable human milk and human-milk-based fortifier for the preterm population. There is a dearth of independent research about the effectiveness and cost-effectiveness of these products.

There is even evidence that individuals who attempt to sell milk online are subject to sexual harassment, including requests for adult wet nursing and explicit photos.

There are more than 500 milk banks operating in over 37 countries around the world. This is a growing industry: in 2017 alone, HMBANA banks dispensed 5.75 million ounces of milk.

Concern about the exploitative nature of a Utah-based human milk company called Ambrosia Labs, which paid women in Cambodia to pump twice daily and shipped the milk supply to US states, resulted in Cambodia banning the practice.

Several US states have legislation governing for-profit milk bank practices. For example,  restrictions include: requiring for-profit companies to follow HMBANA guidelines; requiring donors to delay donating for a minimum amount of time postpartum; and stipulating that most of the bank’s supply be provided to fragile infants in NICU (neonatal intensive care units). In Canada, Health Canada and the Canadian Pediatric Society have guidelines regarding use of banked and shared human milk.

Select Impact Ethics Blogs

 

Select Journal Articles

  • Paynter, M.J., Celis-Hecht Mendoza, A.K. (30 Oct 2018). The Roosevelt Hospital Banco de Leche: Non-Profit human donor milk bank in Guatemala City. Journal of Human Lactation, [Epub ahead], https://doi.org/10.1177/0890334418807465.
  • Paynter, M.J, & Goldberg, L. (2018). A critical review of human milk sharing using an intersectional feminism framework: implications for practice. Midwifery, 66, 141-147. https://doi.org/10.1016/j.midw.2018.08.014
  • Paynter, M., & Hayward, K. (2018).  Medicine, Body Fluid and Food: The Regulation of Human Donor Milk in Canada. Healthcare Policy, 13(3), 20-26. doi:10.12927/hcpol.2018.25400
  • Paynter, M. (2017). Atlantic Canada needs a human milk bank. Canadian Journal of Nursing Research, 49(4), 142-143. https://doi.org/10.1177/0844562117735479
  • Reyes-Foster, B.M., Carter, S.K., & Hinojosa, M.S. (2017). Human milk handling and storage practices among peer milk-sharing mothers. The Journal of Human Lactation, 33(1), 173-180. DOI: 10.1177/0890334416678830
  • Perrin, M.T., et al. (2016). Expanding the supply of pasteurized donor milk: understanding why peer-to-peer milk sharers in the United States do not donate to milk banks. The Journal of Human Lactation, 32(2), 229-237. DOI: 10.1177/0890334415627024
  • Carter, S.K, Reyes-Foster, B.M, & Rogers, T.L. (2015). Liquid gold or Russian roulette? Risk and human milk sharing in the US news media. Health, Risk & Society, 17(1), 30-45. http://dx.doi.org/10.1080/13698575.2014.1000269
  • Palmquist, A.E.L., & Doehler, K. (2015). Human milk sharing practices in the US. Maternal Child Health, 12(2), 278-290. DOI: 10.1111/mcn.12221
  • Gribble, K.D. (2014). ‘I’m happy to be able to help:’ Why women donate to a peer via Internet-based milk sharing networks. Breastfeeding Medicine, 9(5), 251–256. doi: 10.1089/bfm.2014.0009
  • Palmquist, A.E.L., & Doehler, K. (2014). Contextualizing online human milk sharing: structural factors and lactation disparity among middle income women in the U.S. Social Science and Medicine, 122, 140-147. https://doi.org/10.1016/j.socscimed.2014.10.036
  • Gribble, K. D. (2013). Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 42(4), 451-461. doi: 10.1111/1552-6909.12220

Overview

With increasing recognition of the short-and long-term clinical benefits of human milk, and economic, social and clinical barriers to breastfeeding success, demand for donated milk is rising steadily. The World Health Organization recommends using pasteurized human donor milk as a first food for newborns when a parent’s own milk is unavailable for social or clinical reasons. This is particularly important for the preterm population who are at risk of serious complications from gut infections.

Human milk has always been shared among families; wet-nursing is a global and ancient practice. Human milk banks emerged about 100 years ago. At present, both non-profit and for-profit banks exist in North America; for-profit banks can and do compensate “donors” financially whereas non-profit banks only reimburse donor expenses, such as the cost of shipping or of materials including storage bags and cooler gel packs. With the rise of social media, peer-to-peer milk sharing is increasingly commonplace. Peer milk sharing Facebook sites such as Eats on Feets and Human Milk 4 Human Babies facilitate connections between donors and recipients and discourage payment. Milk shared between peers is generally unpasteurized. Human milk may also be purchased online, through private classifieds (usually unpasteurized) or through companies (pasteurized).

Four non-profit milk banks operate in Canada: the Public Mother’s Milk Bank operated by Héma-Québec in Montreal; the Rogers Hixon Ontario Human Donor Milk Bank in Toronto; the Northern Star Mother’s Milk Bank in Calgary; and the BC Women’s Provincial Milk Bank in Vancouver. The Human Milk Banking Association of North America (HMBANA) governs how non-profit milk banks operate. In distributing milk, HMBANA member banks must prioritize the most fragile infants in neonatal intensive care units (NICU) as recipients. Although there is no milk bank east of Quebec, hospitals in New Brunswick, Nova Scotia and Newfoundland purchase milk from the banks in Calgary and Toronto.

HMBANA-member banks must conduct rigorous screening of donors for potentially risky behaviours, similar to blood donation screening. Donors are required to provide negative blood test results for HIV, hepatitis and syphilis. Donation must be approved by the donor’s health care practitioner. After pasteurization, donations are tested for any remaining contamination.  HMBANA banks teach safe milk handling and re-educate donors if bacterial cultures are present after pasteurization.

Milk distributed by banks is subject to the Canada Food and Drug Act. Section 4 prohibits sale of food that is harmful, unfit for human consumption, adulterated, or prepared in unsanitary conditions.  Banks are subject to inspection to monitor compliance.

Historical Timeline

The first organized milk bank opened in Vienna, Austria, in 1909. The first milk bank in North America opened in 1919 in Boston. Milk banking grew steadily throughout the 20th century: in the 1980’s there were 23 milk banks in Canada. During the HIV/AIDS crisis in the 1980’s , fears of transmission through breastmilk resulted in all of these banks closing, except for the BC Women’s Provincial milk bank, which has been open continuously since 1974. Nowadays donors have serology testing for HIV as well as other blood-borne infections.

Four milk banks now operate in Canada. Organized web-based milk sharing in North America began in about 2010 with the emergence of Facebook for platforms.

Payment Debate

Because the HMBANA banks have operating expenditures, staff, and overhead, they charge approximately $4.50/ounce for pasteurized human donor milk. Milk that is provided in-hospital is prescribed and is covered by Medicare like all medications provided to patients while in hospital. Outside of hospital, no private insurer currently covers the cost of donor milk. This is because pasteurized human donor milk does not have a Drug Identification Number (issued by the Therapeutic Products Directorate of Health Canada) and required to be considered for third-party insurance coverage. Eligibility for a prescription for pasteurized human donor milk is determined by clinical and administrative considerations.  For example, a hospital may have a policy that all infants born under 1800 grams or under 34 weeks gestation will be prescribed donor milk with parent/guardian consent to treat.

There are concerns that the cost of pasteurized milk limits its availability. Some suggest remunerating donors as an approach to increase donation.

HMBANA prohibits non-profit member banks from remunerating donors (for example, by the ounce), but allows reimbursement of actual expenses such as shipping costs. There is concern that payment for milk may result in the exploitation of marginalized populations; impact quality by creating an incentive to water milk down; compromise safety in milk handling resulting in microbial contamination; affect donor disclosure about health status; and impact the donors’ other children because milk is sold that otherwise would be available to them.

For-profit human milk companies market products such as shelf-stable human milk and human-milk-based fortifier for the preterm population. There is a dearth of independent research about the effectiveness and cost-effectiveness of these products.

There is even evidence that individuals who attempt to sell milk online are subject to sexual harassment, including requests for adult wet nursing and explicit photos.

Global Picture

There are more than 500 milk banks operating in over 37 countries around the world. This is a growing industry: in 2017 alone, HMBANA banks dispensed 5.75 million ounces of milk.

Concern about the exploitative nature of a Utah-based human milk company called Ambrosia Labs, which paid women in Cambodia to pump twice daily and shipped the milk supply to US states, resulted in Cambodia banning the practice.

Regulatory Frameworks

Several US states have legislation governing for-profit milk bank practices. For example,  restrictions include: requiring for-profit companies to follow HMBANA guidelines; requiring donors to delay donating for a minimum amount of time postpartum; and stipulating that most of the bank’s supply be provided to fragile infants in NICU (neonatal intensive care units). In Canada, Health Canada and the Canadian Pediatric Society have guidelines regarding use of banked and shared human milk.

Media Articles

Further Reading

Select Impact Ethics Blogs

 

Select Journal Articles

  • Paynter, M.J., Celis-Hecht Mendoza, A.K. (30 Oct 2018). The Roosevelt Hospital Banco de Leche: Non-Profit human donor milk bank in Guatemala City. Journal of Human Lactation, [Epub ahead], https://doi.org/10.1177/0890334418807465.
  • Paynter, M.J, & Goldberg, L. (2018). A critical review of human milk sharing using an intersectional feminism framework: implications for practice. Midwifery, 66, 141-147. https://doi.org/10.1016/j.midw.2018.08.014
  • Paynter, M., & Hayward, K. (2018).  Medicine, Body Fluid and Food: The Regulation of Human Donor Milk in Canada. Healthcare Policy, 13(3), 20-26. doi:10.12927/hcpol.2018.25400
  • Paynter, M. (2017). Atlantic Canada needs a human milk bank. Canadian Journal of Nursing Research, 49(4), 142-143. https://doi.org/10.1177/0844562117735479
  • Reyes-Foster, B.M., Carter, S.K., & Hinojosa, M.S. (2017). Human milk handling and storage practices among peer milk-sharing mothers. The Journal of Human Lactation, 33(1), 173-180. DOI: 10.1177/0890334416678830
  • Perrin, M.T., et al. (2016). Expanding the supply of pasteurized donor milk: understanding why peer-to-peer milk sharers in the United States do not donate to milk banks. The Journal of Human Lactation, 32(2), 229-237. DOI: 10.1177/0890334415627024
  • Carter, S.K, Reyes-Foster, B.M, & Rogers, T.L. (2015). Liquid gold or Russian roulette? Risk and human milk sharing in the US news media. Health, Risk & Society, 17(1), 30-45. http://dx.doi.org/10.1080/13698575.2014.1000269
  • Palmquist, A.E.L., & Doehler, K. (2015). Human milk sharing practices in the US. Maternal Child Health, 12(2), 278-290. DOI: 10.1111/mcn.12221
  • Gribble, K.D. (2014). ‘I’m happy to be able to help:’ Why women donate to a peer via Internet-based milk sharing networks. Breastfeeding Medicine, 9(5), 251–256. doi: 10.1089/bfm.2014.0009
  • Palmquist, A.E.L., & Doehler, K. (2014). Contextualizing online human milk sharing: structural factors and lactation disparity among middle income women in the U.S. Social Science and Medicine, 122, 140-147. https://doi.org/10.1016/j.socscimed.2014.10.036
  • Gribble, K. D. (2013). Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 42(4), 451-461. doi: 10.1111/1552-6909.12220