Abstract
Introduction:
Human Milk Banking (HMB) has emerged as an effective strategy to provide pasteurized Donor Human Milk (DHM) when a mother’s own milk is unavailable or insufficient. This study assessed newborn feeding practices and awareness and attitude toward human milk donation among postnatal mothers.
Materials and Methods:
A cross-sectional study was conducted for 3 months among 206 mothers admitted to postnatal wards under a tertiary care institute of Kolkata. The mothers were selected by systematic random sampling, and face-to-face interviews were conducted using an interview schedule, which also included an observation checklist to assess the newborn feeding practices. Descriptive and inferential statistics were employed as applicable.
Results:
The mean age of study participants was 25.1 (±2.9) years. Almost 92.1% of mothers fed their newborns with breast milk. Around 63% were unaware that DHM is the best alternative for preterm infants when mothers’ own milk is unavailable. Nearly half (49%) reportedly had low awareness, while 42% had unfavorable attitude toward human milk donation. Only 32% were aware of an established HMB in the study setting. Mothers’ education had statistically significant associations with newborn feeding practices and awareness of human milk donation, respectively.
Conclusion:
Almost half of the mothers had low awareness and unfavorable attitude toward human milk donation. Increased awareness campaigns, workshops are needed to be conducted to generate more awareness regarding milk donation and HMB.
Keywords: Awareness, donor human milk, human milk banking, human milk donation, newborn feeding practices
Introduction
Optimal nutrition for infants is a cornerstone of public health, with profound implications for not only the immediate survival, growth, and cognitive development but also the long-term health outcomes. The World Health Organization and UNICEF have consistently recommended exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with complementary feed for up to 2 years or beyond.[1] Human milk contains an optimal balance of nutrients, bioactive compounds, immunological factors, and microbiota that support infant development in ways that cannot be replicated by artificial formulas.[2] Despite these recommendations, breastfeeding rates in India remain suboptimal, with the National Family Health Survey-5 (2019–2021) report stating that only 64.9% of infants under 6 months are exclusively breastfed, with significant regional variations.[3] In West Bengal specifically, the exclusive breastfeeding rate stands at 53.3%, below the national average, highlighting a critical public health concern.[4]
The challenges of establishing and maintaining breastfeeding are particularly pronounced for mothers of preterm, low birth weight, or sick newborns. These vulnerable infants have higher nutritional requirements but often face barriers to receiving mother’s own milk, including maternal illness, stress, separation from the infant, and physiological challenges in milk production.[5] Furthermore, in urban settings like Kolkata, factors such as limited maternity leave, inadequate workplace support for breastfeeding, and aggressive marketing of breast milk substitutes further complicate adherence to optimal feeding practices.[6] Human Milk Banking (HMB) has emerged as an effective strategy providing pasteurized donor human milk (DHM) when a mother’s own milk is unavailable or insufficient. HMBs collect, screen, process, and distribute donated breast milk to infants in need, prioritizing those at highest risk.[7] The practice of milk banking began in Vienna in 1909 and has since expanded globally, with over 750 active milk banks worldwide.[8] In India, the first HMB was established in 1989 at Lokmanya Tilak Municipal General Hospital, Mumbai, and the country now has approximately 87 operational milk banks, though their distribution remains uneven across regions.[9]
The processing of DHM follows strict protocols established by organizations like the HMB Association of India. These include rigorous donor screening, milk collection under hygienic conditions, holder pasteurization (62.5°C for 30 min), microbiological testing, and temperature-controlled storage.[10] A systematic review by Quigley et al.[11] found that infants fed with DHM had a 19% reduced risk of developing necrotizing enterocolitis compared to formula-fed infants. In addition, Miller et al.[12] documented improved feeding tolerance, reduced hospital stay duration, and better neurodevelopmental outcomes in vulnerable infants receiving donor milk. A cross-sectional study in Delhi found that only 34% of postpartum mothers were aware of the concept of milk donation, with even fewer (17%) familiar with the existence of milk banks.[13] Similarly, research from Karnataka revealed that while 79% of mothers expressed willingness to donate milk after explanation of the concept, initial awareness was limited to 31%.[14,15] Research by Mondkar et al.[16] identified religious and cultural beliefs, concerns about safety and screening procedures, and misconceptions about the effect of donation of one’s own milk as significant barriers to donation.[16,17]
Understanding regional variations in awareness and attitudes is crucial, as cultural practices and beliefs surrounding breastfeeding and milk sharing differ significantly across India’s diverse regions.[18]
Despite the existence of milk banking facilities in some tertiary care centers in Kolkata, no comprehensive assessment of maternal knowledge, attitudes, and practices regarding HMB has been conducted in this region. This knowledge gap hampers the development of targeted educational interventions and culturally sensitive promotion strategies that could enhance milk donation rates and acceptance of donor milk.[19] Hence, the study aimed to address these gaps by assessing the practices of postnatal mothers toward newborn feeding, evaluating their perceptions of HMB, and determining the factors influencing these perceptions and practices in a tertiary care institute in Kolkata.
Materials and Methods
Study type, design, study setting, and duration
A descriptive study with cross-sectional design was conducted in the maternity wards (postnatal units) of the Institute of Post Graduate Medical Education and Research (IPGME and R) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Kolkata, and Khidirpur Maternity Home (KMH) – the Annex V unit of IPGME and R and SSKM Hospital, respectively, for a period of 3 months (February 2025 to April 2025).
Study participants, inclusion and exclusion criteria
All postnatal mothers admitted at the maternity wards of IPGME and R and SSKM Hospital and KMH, respectively, during the study period, were chosen as study participants. In this study, the postnatal mothers who underwent any type of delivery (normal vaginal delivery, assisted, or LUCS) were included, while those who did not give written consent to participate in the study were excluded.
Sample size estimation (n) and sampling technique
Considering prevalence (p) of early initiation of breastfeeding among postnatal mothers admitted in a tertiary care hospital of Kolkata as 77.5% from a study conducted by Chakraborty and Joardar,[20] by applying Cochran’s formula: z2 × pq/d2; where P = 77.5% or 0.775, q = (1–p) = 0.225, Z(1−α/2) = 1.96 at 95% confidence interval (CI) with absolute error (d) = 7%; the minimum calculated sample size was,
n = ([1.96]2 × 0.775 × 0.225)/(0.07)2 = 137
After multiplying by a design effect of 1.5 and rounding off, the final sample size was obtained as 206.
A systematic random sampling technique was employed to draw the eligible study participants into the desired sample. The approximate number of admissions per month in the Postnatal wards of IPGME and R and SSKM Hospital and KMH were obtained by reviewing the admission registers of the last 6 months. It was observed that the total number of admissions of postnatal mothers per month in both hospitals was approximately 615. The calculated sample size (n) was 206. Hence, the “sampling interval” (k) was (615/206) = 2.98–3. Thus, every “3rd” postnatal mother was drawn into the sample as study participants, till the desired sample size of 206 was achieved, keeping in mind the exclusion criteria.
Study tools and study technique
A predesigned, pretested, and structured schedule was employed to collect data from the mothers that met the eligibility criteria. The schedule contained a mixture of open-ended and semi-open-ended, single and multiple response questions, which collected data across the domains of sociodemographic characteristics of the study participants, practices regarding newborn feeding, their awareness and attitude toward human milk donation. It was prepared in English, under the guidance of three subject experts of the Department of Community Medicine of the institution, and was then translated into Bengali and Hindi languages with the help of respective language experts. Back translation into English was done by two other language experts to check for validity and reliability. The content validity was checked using Content Validity Index, which was 0.77, and Cronbach’s alpha was calculated to assess the reliability of the questionnaire (0.71). Before data collection, the schedule was pretested among 20 mothers of the Postnatal wards of IPGME and R (who were later excluded from the final sample), and accordingly, necessary corrections were incorporated into the schedule before administering it to the participants.
Data were collected for 3 days (Tuesday, Thursday, and Saturday) every week for 4 weeks. In the first 2 weeks, data were collected from the mothers admitted at IPGME and R and SSKM Hospital, followed by the next 2 weeks at KMH. All the eligible participants were thoroughly explained the purpose of the study, and written consent was obtained from them prior to data collection. Face-to-face interviews were conducted, and the observation checklist was used for assessing the feeding practices of the participants toward their newborn.
Study variables
Dependent variables were newborn feeding practices, awareness of the participants on human milk donation, and their attitude toward HMB, whereas the independent variable was sociodemographic characteristics.
Statistical analysis
Data were first tabulated and interpreted using Microsoft Office (MS Office) Excel 2021. Subsequent analyses were conducted using the Statistical Package for the Social Sciences (SPSS for Windows, version 26.0; SPSS Inc., Chicago, IL, USA).
The Newborn feeding practices of the participants were assessed using seven questions and three observations. Each item was scored as “0” for “improper” practice and “1” for “proper” practice. The questions included whether the child was exclusively breastfed, whether feeding was initiated within one hour of birth, colostrum feeding, any history of prelacteal feeding, feeding frequency, demand feeding, and night feeding. The observation checklist assessed the child’s positioning during feeding, latching, and suckling pattern. The total score ranged from 0 to 10, with a median value of “9.” Feeding was classified as “proper” if the score was ≥9 and “improper” if the score was <9. Awareness of human milk donation was assessed using an 11-item questionnaire based on a 3-point Likert scale with response options ranging from “Yes,” “No,” and “Don’t know.” Each correct response was awarded a score of “1,” while incorrect or uncertain responses were scored “0,” resulting in a total score ranging from 0 to 11. Based on the median awareness score of “3,” participants with scores ≥3 were classified as having “high” awareness, and those with scores <3 as having “low” awareness. Attitude toward human milk donation was assessed using a 9-item questionnaire on a 3-point Likert scale with response options: “Agree,” “Neutral,” and “Disagree.” Responses were scored as follows: “Agree” = 2, “Neutral” = 1, and “Disagree” = 0, yielding a total possible score range of 0–18. Based on the median attitude score of “12,” participants scoring ≥12 were classified as having a “favorable” attitude, whereas those scoring <12 were classified as having an “unfavorable” attitude.
Pearson’s Chi-square tests were performed to check for associations of sociodemographic characteristics of the participants with their newborn feeding practices, awareness, and attitude towards human milk donation. P < 0.05 at 95% CI was considered statistically significant. Spearman’s Correlation test (rho) was run to check for correlation between the awareness and attitude domain. Here, P < 0.01 was taken as statistically significant (two-tailed).
Ethical considerations
Permission from the Institutional Ethics Committee (IEC) of IPGME and R and SSKM Hospital, Kolkata, was obtained before the commencement of the study (IPGME and R/IEC/2025/0094). Informed written consent was taken from each participant before conducting the interviews and completing the observation checklist. A prior permission to conduct the study was also obtained from the Head of the Obstetrics-Gynaecology Department of IPGME and R and SSKM Hospital, and from the Superintendent of KMH, after obtaining approval from the IEC. Anonymity and confidentiality of data were maintained throughout the study.
Operational definitions
Awareness is perception or knowledge of something. Accurate reportability of something perceived or known is widely used as a behavioral index of conscious awareness; however, it is possible to be aware of something without being explicitly conscious of it[21]
Explicit attitudes are conscious and deliberate evaluations that individuals can report, whereas implicit attitudes are unconscious, automatic responses that influence behaviour without awareness.[22]
Results
Sociodemographic profile
The mean age of the study participants was 25.1 years, with a standard deviation of ± 2.9, and the median age is 26 years. Almost 37% followed Hinduism, and most of them (66%) resided in urban areas. Nearly 62% of the participants had received education at secondary school level or higher, which is more as compared to their husbands (50%). Almost 71% belonged to the lower (Class V) socioeconomic status as per the Modified B.G. Prasad scale (updated in 2024).[23]
Obstetric history
More than two-thirds (69%) had undergone a cesarean section. More than half (65.91%) of the mothers had term deliveries. Almost 73% of the babies were 1–3 days old. More than half (60.4%) had delivered male babies. Nearly 92% newborns were healthy, while only 10% developed some neonatal complications.
Feeding practices
Most of the participants (97%) had initiated breastfeeding, out of which, almost half (51%) of had initiated breastfeeding within 1 h, and 48.3% initiated breastfeeding within 1–24 h. Almost 97% newborns had received colostrum. Very few (7.1%) of the participants had introduced their newborns to pre-lacteal feed (formula milk). Most of the newborns (92.1%) were exclusively breastfed, in contrast, a few (11%) were not. Among them, 5% received expressed breast milk, 3% received formula milk, whereas 2% relied on mixed feeding. Proper positioning of the baby was noted in almost 85% of the participants. Correct attachment was observed in nearly 81% mothers. A good suckling pattern was seen in almost 77% of the neonates. Almost 90% of mothers breastfed their babies more than 8 times a day. In addition, night feeds were given by 95.9% of the mothers.
Awareness of human milk donation
Only 35% of study participants were aware of HMB. Almost 63% were unaware that DHM is the best alternative for preterm infants when mother’s milk is unavailable. More than half (61.2%) of the participants were unaware that donor milk is nutritionally superior to formula milk. Around 63% of study participants were unaware that feeding preterm infants with DHM facilitates their growth and recovery from diseases. Almost 68% were unaware that mothers who have excess breast milk can donate it [Table 1].
Table 1.
Distribution of study participants according to their responses on awareness of human milk donation (n=206)
| Items | Yes, frequency (%) | No, frequency (%) | Don’t know, frequency (%) |
|---|---|---|---|
| “Are you aware that DHM is the best alternative for preterm infants when the mother’s milk is insufficient or unavailable?” | 67 (32.5) | 131 (63.6) | 8 (3.8) |
| “Are you aware that for preterm infants, DHM is nutritionally superior to formula?” | 69 (33.5) | 126 (61.2) | 11 (5.3) |
| “Are you aware that most nutrients of DHM are destroyed after pasteurization?” | 33 (16.0) | 155 (75.2) | 18 (8.7) |
| “Are you aware that feeding preterm infants with donor human milk facilitates their growth and recovery from disease?” | 62 (30.1) | 130 (63.1) | 14 (6.8) |
| “Are you aware that mothers who donate human milk are required to undergo a health screening?” | 46 (22.3) | 149 (72.3) | 11 (5.3) |
| “Are you aware that mothers who have excess breastmilk can donate it?” | 58 (28.2) | 140 (68.0) | 8 (3.8) |
| “Are you aware that after pasteurization, DHM is stored frozen and is valid for 3 to 6 months?” | 21 (10.2) | 171 (83.0) | 14 (6.8) |
| “Are you aware that DHM should be stored in HMB?” | 52 (25.2) | 144 (69.9) | 10 (4.8) |
| “Are you aware that DHM needs to be pasteurized before it can be given to infants?” | 27 (13.1) | 164 (79.6) | 15 (7.3) |
| “Are you aware that HMB can save the lives of preterm or sick newborns?” | 55 (26.7) | 142 (68.9) | 9 (4.3) |
| “Are you aware that mothers who consume tobacco and/or alcohol or have any diagnosed communicable disease like HIV/Hepatitis B or C/syphilis, etc., cannot donate breastmilk?” | 30 (14.6) | 158 (76.7) | 18 (8.7) |
DHM: Donor Human Milk; HMB: Human Milk Banking; HIV: Human immunodeficiency virus
Overall, 49% participants had “low” awareness of human milk donation.
Most of the participants (174 [84.4%]) were unaware of the presence of an HMB (“Madhur Sneha”) in the hospital. Among those who were aware (32 [15.5%]), the most common source of information was healthcare workers (22) employed at the hospital (doctors, nurses, etc.).
Attitude toward human milk donation
Among the mothers, 64% agreed to donate their breast milk to HMB if required in future. Around 61% agreed to accept DHM for their babies if needed. More than one-third (39.8%) of disagreed having concerns regarding HMB, such as safety, religious beliefs, and social stigma. Nearly 68% agreed that all breastfeeding mothers should be informed about and encouraged to donate excess milk to HMB [Table 2]. Overall, “favorable attitude” was seen in 58% and “unfavorable attitude” in 42% of the participants towards human milk donation.
Table 2.
Distribution of study participants according to their responses on attitude toward of human milk donation (n=206)
| Items | Agree, frequency (%) | Neutral, frequency (%) | Disagree, frequency (%) |
|---|---|---|---|
| “I will donate my breastmilk to the human milk bank if required in the future” | 132 (64.0) | 51 (24.7) | 23 (12.3) |
| “I will accept DHM for my baby if needed” | 125 (60.6) | 48 (23.3) | 33 (17.74) |
| “I have concerns regarding human milk banking, such as safety, religious beliefs, social stigma, etc.” | 51 (24.7) | 82 (39.8) | 73 (39.26) |
| “I would not like to feed my baby with the breastmilk of a woman that I do not know” | 53 (25.7) | 72 (34.9) | 81 (43.55) |
| “A certain amount of money should be paid to the women who donate their breastmilk” | 47 (22.8) | 97 (47.1) | 62 (33.33) |
| “All breastfeeding mothers should be informed about and encouraged to donate to human milk bank” | 141 (68.4) | 58 (28.1) | 7 (3.76) |
| “The milk taken from the milk bank may hinder the bonding with my baby” | 44 (21.3) | 89 (43.2) | 73 (39.24) |
| “DHM from the milk bank will not favour growth and development of my baby unlike my own milk” | 34 (16.5) | 81 (39.3) | 91 (48.92) |
| “I feel that thorough knowledge regarding human milk donation and banking is important for lactating mothers” | 149 (72.3) | 55 (26.7) | 2 (1.07) |
DHM: Donor Human Milk
Pearson’s Chi-square tests showed that participants’ age and education were significantly associated with newborn feeding practices (P < 0.001) [Table 3]. Education of both participants (P = 0.04) and their husbands (P = 0.03) was significantly associated with awareness of human milk donation [Table 4].
Table 3.
Associations of sociodemographic characteristics with newborn feeding practices (n=206)
| Sociodemographic characteristics | Newborn feeding practices |
χ2, df | P | ||
|---|---|---|---|---|---|
| Proper, n (%) | Improper, n (%) | Total, n (%) | |||
| Age of the participants (completed years) | |||||
| <26 | 57 (55.9) | 45 (44.1) | 102 (100) | 21.8, 1 | <0.001 |
| ≥26 | 25 (24.0) | 79 (76.0) | 104 (100) | ||
| Highest level of education attained by participants | |||||
| Middle school or below | 50 (58.8) | 35 (41.2) | 85 (100) | 22.1, 1 | <0.001 |
| Secondary and above | 32 (26.4) | 89 (73.6) | 121 (100) | ||
P<0.05=statistically significant
Table 4.
Association of sociodemographic characteristics with awareness of human milk donation (n=206)
| Sociodemographic characteristics | Awareness of human milk donation |
χ2, df | P | ||
|---|---|---|---|---|---|
| High, n (%) | Low, n (%) | Total, n (%) | |||
| Highest level of education attained by participants | |||||
| Middle school or below | 35 (41.2) | 50 (58.8) | 85 (100) | 4.1, 1 | 0.04 |
| Secondary and above | 67 (55.4) | 54 (44.6) | 121 (100) | ||
| Highest level of education attained by husbands of the participants | |||||
| Middle school or below | 53 (57.6) | 39 (42.4) | 92 (100) | 4.35, 1 | 0.03 |
| Secondary and above | 49 (43.0) | 65 (57.0) | 114 (100) | ||
P<0.05=statistically significant
Awareness and attitude toward human milk donation had moderately positive correlation, which was also statistically significant (Spearman’s correlation coefficient [rho] = 0.23 [two-tailed] at P < 0.001) [Figure 1].
Figure 1.
Scatter plot showing correlation between the awareness and attitude scores (n = 206)
Discussion
A study conducted by Ahmed et al.[24] revealed that the acceptance to donate human milk among postnatal mothers at St. Francis Hospital Nsambya was very high (almost 77%). Willingness to express and store human milk, prior knowledge about wet nursing, and a visit to an under-five outpatient clinic were associated with acceptance. Thus, establishing a human milk bank is feasible in the study setting, as per the study. In contrast, the present study revealed that almost half of the mothers had high awareness, whereas most of them had favorable attitude toward human milk donation. Mothers’ education had significant associations with the newborn feeding practices and awareness of human milk donation. Awareness and attitude scores also had a moderately positive correlation, which was statistically significant.
According to another study done by Mampane and Wolvaardt[25] in Limpopo Province of South Africa, the study participants were unaware of the donation of human milk. Hesitancy in accepting DHM due to fear of contracting HIV was observed. Cultural beliefs are an influencing factor for use, whereas donation was driven by altruistic reasons, preventing waste, helping others, and having previously benefited from DHM. The study found that mothers are willing to donate human milk. Willingness to donate can be increased by raising awareness about HMB and addressing culture and safety concerns at antenatal clinics. The present study revealed that almost half of the mothers had high awareness, while most of them had a favorable attitude toward human milk donation. Mothers’ education had significant associations with the newborn feeding practices and awareness of human milk donation. Awareness and attitude scores also had a moderately positive correlation which was statistically significant.
In a study done by Zobbi et al.[26] in Italy, among the study subjects, 76.57% knew about the opportunity to donate human milk, and 72.37% were aware of the existence of HMBs; most of them breastfed for more than 6 months. Altruism toward other mothers and having an abundant milk supply were found to be the most important facilitators that should lead women to donate their own milk. The most important barrier was a lack of information (91.25%). In the current study, nearly 68% agreed that all breastfeeding mothers should be informed about and encouraged to donate excess milk to HMB. Almost 48% disagreed that the donated milk from the HMB will not favor the growth and development of their babies. This highlights the importance of the emotional bonding between the mothers and their newborns, which is believed to be established through breastfeeding.
A qualitative study conducted among 56 mothers by Chugh et al.[27] in two urban hospitals in India, it was found that most of the participants were unaware of the recommended duration of exclusive breastfeeding. Most parents knew about the benefits of breast milk and colostrum. Limited staff and privacy in facilities resulted in inadequate breastfeeding and milk expression support to mothers, who found feeding of preterm and low-birth-weight babies challenging. In the present study, it was seen that almost half of the postnatal mothers had high awareness of human milk donation, while most of them had a favorable attitude toward the same. Almost 68% had no idea of the existence of an HMB in the study area. Mothers’ education had significant associations with the newborn feeding practices and awareness of human milk donation. It is believed from the studies that people globally may have concerns about the safety of donor milk, despite the stringent screening and pasteurization processes used by milk banks. These concerns may include fear of disease transmission, questions about the quality and handling of donated milk. Furthermore, mothers may have a strong desire for their own milk to be the sole source of nourishment for their baby, making them hesitant to accept donor milk.
Prevalence of prelacteal feed reduced, and initiation of early breastfeeding increased considerably after the launch of the National Rural Health Mission in India, according to a study done by Mal and Ram.[28] However, after 2015–2016, early breastfeeding initiation has stagnated, and the decline in prelacteal feed has slowed down. The findings also suggested that an early breastfeeding initiation is associated with lower neonatal mortality, whereas pre-lacteal feed is not harmful compared to late breastfeeding initiation. As mentioned earlier, in the present study, it was seen that only 7% mothers had given prelacteal feed to their newborns. Almost half of the postnatal mothers had high awareness of human milk donation, whereas most of them had a favorable attitude toward the same. Almost 68% had no idea of the existence of an HMB in the study area. Mothers’ education had significant associations with the newborn feeding practices and awareness of human milk donation.
Strengths and limitations
This is a novel study, since there is a dearth of existing studies or sufficient literature on HMB and milk donation. There is an HMB in the hospital (IPGME and R), which is believed to be subjected to better utilization of services following awareness generation among the mothers towards HMB and human milk donation.
However, a community-based study assessing the awareness and attitude of mothers, including their newborn feeding practices, could have been better. Furthermore, due to time constraints, a larger sample size was not considered in the study.
Conclusion and Recommendations
Almost half of the mothers had high awareness, while most of them had favorable attitude toward human milk donation. Mothers’ education had significant associations with the newborn feeding practices and awareness of human milk donation. Awareness and attitude scores also had a moderately positive correlation, which was statistically significant.
Awareness generation among the mothers, nursing staff, and other healthcare professionals in the hospital regarding human milk donation and the presence of HMB through sensitisation programmes at frequent intervals should be meticulously conducted. Posters, banners, and other relevant IEC (Information, Education, and Communication) materials, at the maternity wards at IPGME and R and KMH, regarding proper positioning and attachment, and importance of breastfeeding should also be done. Posters, banners, and signage regarding the HMB (“Madhur Sneha”) at strategic locations inside the IPGME and R premises for raising awareness among the patients is the need of the hour.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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