‘Your baby can take my milk… but my baby won’t take yours’; determinants of willingness to donate and utilize human breast milk among pregnant women at a health facility in limited resource settings

Abstract

Background

Donor human milk is vital for newborn nutrition and development. The World Health Organization advocates donor human milk when maternal milk is unavailable. In alignment with this global recommendation, Kenya has established a donor human milk bank to support vulnerable infants and improve neonatal health outcomes. However, the willingness of mothers to use or donate human milk, as well as their related practices and attitudes, remains an area that requires further exploration.

Objective

This study explored the willingness of pregnant women at Pumwani Maternity Hospital to donate and use human breast milk.

Methods

This qualitative study sought to establish participants’ views on their willingness to donate and use human breast milk was conducted in August 2023. Eligible participants were pregnant women attending Kenya’s largest public maternity hospital. Three focus group discussions were held and tape-recorded and transcribed verbatim. The data were analyzed using thematic data analysis with results reported verbatim.

Results

Most participants were aged 21–39 years, were married and had either secondary or tertiary education. Awareness of donor human milk and milk banking was low; over half had never heard of milk donation or seen a child fed with donated milk. However, most of the participants indicated that they were open to donating their own breast milk to the milk bank, perceiving it as a noble cause, particularly if they had surplus supply and were medically eligible. Majority were however less inclined to allowing their babies to use donated human milk unless it were unavoidable or extremely necessary. Concerns included fear of disease transmission, mistrust and cultural discomfort. Acceptance was more likely if advised by a healthcare provider or in severe maternal illness or insufficient milk supply.

Conclusion

The mothers’ awareness of human breast milk donation and banking was suboptimal and most exhibited reservations about allowing their babies to be fed with donated human milk despite their expressed willingness to donate their breast milk. This highlights the crucial need for targeted education campaigns to address concerns and promote the acceptance of donated human milk among the pregnant women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-026-00835-8.

Background

Breast milk, the primary source of nutrition for newborns contains all the nutrients the baby requires for healthy growth and development [1] and also contains antibodies that protect them against infections. The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend initiation of breastfeeding within the first hour of birth and exclusive breastfeeding for the first six months of life, followed by continued breastfeeding and complimentary feeding. According to The World Health Organization, breastmilk is the best newborn feeding option that can save lives especially for preterm, low birth weight, orphaned, malnourished and critically ill infants [2, 3] as it offers essential antibodies thus providing superior protection against infections compared to formula milk. Breast milk is easily digested, absorbed and well tolerated thus reduced risk of getting severe conditions like necrotizing enterocolitis, a severe, often fatal, inflammatory intestinal disease, and respiratory conditions [2, 4]. Consequently, breastmilk supports optimal growth, neurological development, and hence reduces hospital stays.

When a mother’s own milk is unavailable or insufficient, donor human milk is the recommended option [5, 6]. Donor human milk is collected, screened and processed before distribution to human milk banks operating under safety and quality protocols. Globally, over 60 countries operate human milk banks though most are located in Europe, United States (US), Asia and Brazil. In the year 2020, there were 756 human milk banks in 66 countries worldwide with a modest but growing number of human milk banks in low and middle-income countries [7, 8].

Despite the global expansion of human breastmilk banking, its utilization in Africa remains limited. Only seven countries; South Africa, Angola, Mozambique, Kenya, Uganda, Cameroon and Cape Verde currently have operational human milk banks [1, 9]. In Kenya, the first and only human milk bank was established at Pumwani Maternity Hospital, the largest public maternity hospital in the country. Priority for the donated human milk is given to the preterm babies; the abandoned and orphaned newborns and sick newborns whose mothers have inadequate milk needed for the babies. The donated human milk is given on prescription after assessment of the mother and the baby. Milk donation is from the mothers who have surplus after feeding their own babies and are willing to donate. Although the initiative has benefitted these categories of infants, its uptake remains suboptimal.

The successful adoption and sustainability of breastmilk banking depend largely on the awareness, perceptions and acceptance of donor human milk. There is limited qualitative evidence exploring how pregnant women in Kenya perceive breastmilk donation and use of donated human milk for their own infants. Understanding their perceptions and attitudes may shape the acceptance and use of donor human milk. This study explored the awareness, perception of human milk donation and willingness to use donated human milk among pregnant women in the hospital.

Methods

Aim of the study

This study aimed to explore the awareness and perceptions of pregnant women regarding donor human milk and human milk banks. Specifically, it examined their knowledge of breast milk banking, attitudes toward donating breast milk for use by other infants, and their willingness to feed their own babies with donated human milk.

Study design

A qualitative descriptive study design was utilized to draw insights regarding the participants’ willingness to donate and use human breast milk in a local public referral maternity hospital.

Study setting

The study was conducted at Pumwani Maternity Hospital (PMH), a public referral maternity hospital located in Nairobi County, Kenya. It offers specialized in and out-patient maternal, infants and child health services in a wide range of medical specialties. It has 2 theaters, 354 obstetric beds and 144 baby cots. Daily normal deliveries average about 50–100 and caesarean sections are about 10–15 daily. The average number of babies in its Newborn Unit is 90 with half of them admitted with prematurity. The study was conducted in its antenatal clinic and the facility was purposively selected as the study setting because it is the only hospital in the country with a human milk bank.

Study population and sample

A total of 21 mothers participated in the study. This sample size was considered adequate for qualitative study design where the aim is to gain in-depth insights of participants perceptions and thematic data saturation, where data collection ceased when no new insights or themes emerged from the discussions indicating sufficient information [10]. Three focus group discussions (FGDs) were conducted, with 6–9 participants per FGD, consistent with recommended sizes for productive group interaction. The participants were purposively selected as soon-to-be mothers attending antenatal care, the primary population of interest for understanding perceptions of human milk banking. This sample is considered both adequate and informative for exploring this topic, which remains novel and under-discussed in this community.

Inclusion and exclusion criteria

All consenting pregnant women aged 18 years and above were eligible irrespective of their gestational period. However, those with medical, surgical, or gynecological conditions or who were too weak to respond were excluded.

Recruitment

Participants were recruited after completing their antenatal care activities for the day. The nurse research assistant approached eligible mothers at their final consultation station, where the study was introduced and explained. Approaching participants at the conclusion of their clinic visit ensured voluntary participation and minimized any perception of coercion or concern that declining to participate might affect the care they received at the facility.

Recruitment was conducted consecutively, with eligible mothers approached before 10:00 a.m. to allow sufficient time for them to resume their daily responsibilities after the Focus Group Discussions (FGDs). Once the required number of participants for an FGD had been attained, the session was conducted, and participants were released thereafter. No compensation was provided for participating in the study; however, each participant received a modest transport reimbursement of USD 2 to account for potential fare increases due to possible delays.

Data collection and analysis

Data were collected in August 2023, using focus group discussions (FGD). Two research assistants who were nurses by profession were trained in conducting the FGDs. The FGD guide consisted of questions on the participants’ awareness of human breast milk donation as well as on their willingness to donate and utilize human breast milk.

Prior to the main study, the FGD guide was pretested at the maternity unit of Mama Lucy Kibaki hospital, a county hospital, located within Nairobi County to assess clarity and appropriateness of the questions. Feedback from the pretest informed minor adjustments to the wording and sequence of questions. No data from the pretest phase was included in the analysis.

Mothers were approached face to face by the nurse research assistant and were invited into a designated room within the clinic for the FGD. After administering informed consent, the mothers were interviewed in a well-ventilated room with minimal noise. Covid-19 control measures were observed, including social distancing.

The discussions were audio-recorded using a digital voice recorder, and interview notes were also taken during the interviews. For quality control purposes, the recordings were played back to the respondents, allowing each participant the opportunity to withdraw any statement they wished. None of the mothers chose to recant any statements. Three FGDs consisting of 6–9 mothers were conducted, each taking 45 min to one hour. The data generated from the discussions were probed using thematic analysis and findings were reported verbatim with NVivo Version 12.0 as the analytical computer software utilized. To thematically analyze the data, we followed the Braun and Clarke 6-step framework [11]. This began with familiarization, which entailed careful and thorough listening of the interviews’ audio recordings and reading of the field notes to gain insights into the phenomenon under study. This was followed by the transcribing of the interviews, in which the study interviews were transcribed verbatim. Coding and theme derivation followed in which the transcribed data was coded and categorized by JK and FO to characterize its content. A codebook (Supplementary Table 1) was developed to categorize the themes, sub-themes, codes, definitions and verbatim quotes from the participants. This codebook served as a framework for thematic analysis and ensured consistency in data interpretation. Meanings were derived from the significant statements through repeated comparisons to establish patterns. The patterns were eventually evaluated and compared with the field notes to find potential themes. This was followed by data analysis in which key concepts and ideas emanating from the transcripts were grouped into theme clusters with major themes being created by combining related theme clusters. This was then followed by validation of the findings which was a re-look of the transcripts, thematic clusters and identified major themes to look for any discrepancies or opposing viewpoints, remove any superfluous data and to make sure that the identified themes and sub-themes were complete and comprehensive. A final comprehensive write-up of the findings was then made by JK, MK and LK. This systematic approach to the analysis was critical as it established an audit trail from the transcripts of raw data through to the final interpretation. Data collection ceased when thematic data saturation was reached, with the data analysis confirming coherence of the identified themes. Integrity of the collected data was upheld by ensuring that research assistants were well-trained on the data collection process and thorough checking for clarity and completeness of the collected data.

Ethical considerations

The KNH-UoN Ethics and Research Committee (ERC) approved the study (Ref: KNH-ERC/A/484) while permission to undertake the study at PMH antenatal clinic was granted by the hospital’s management. Research permit was issued by NACOSTI (NACOSTI/P/23/30578). Participants gave informed consent and participated voluntarily. Obtained data were processed and reported anonymously. Covid-19 safety measures were observed during the interviews and ethical principles of autonomy, anonymity and confidentiality, non-maleficence, and justice were observed.

Study limitations

The study findings reflect views of pregnant women attending a single selected hospital and hence may not represent views of all other mothers in the country, including views of mothers who attended antenatal clinics in hospitals that had no human milk banks.

Results

The study explored three major aspects which included the participants’ awareness of human breast milk donation; their willingness to donate their own breast milk; and their willingness to utilize donated human breast milk. This is however preceded by findings on the participants’ demographic characteristics.

Demographic characteristics of the participants

The respondents were pregnant women attending antenatal care clinics at the Pumwani Maternity Hospital. Majority (90.4%) of the participants were aged 21–39 years; were married (80.9%) and had either secondary (47.6%) or tertiary level (38.1%) education. On occupation, nearly half (47.6%) were self-employed while a third (33.3%) were unemployed. In addition, majority were Christians (95.2%) and had 1–3 children (95.2%). Most had attended antenatal clinics for less than 4 times (66.7%) (Table 1).

Table 1.

Participants’ socio-demographic characteristics of mothers attending antenatal clinic at the Pumwani Maternity Hospital

		Frequency	Percent
Age (in years)	≤ 20 years	1	4.8
	21–30 years	12	57.1
	31–39 years	7	33.3
	40 years and above	1	4.8
	Total	21	100.0
Marital status	Single	3	14.3
	Married	17	80.9
	Separated	1	4.8
	Total	21	100.0
Education level	Primary	3	14.3
	Secondary	10	47.6
	College/University	8	38.1
	Total	21	100.0
Religion	Christian	20	95.2
	Muslim	1	4.8
	Total	21	100.0
Occupation	Self-employed	10	47.6
	Formally employed	1	4.8
	Casual	3	14.3
	Unemployed	7	33.3
	Total	21	100.0
Number of children	1–3	20	95.2
	4 and above	1	4.8
	Total	21	100.0
Number of antenatal clinic visits made	< 4 times	14	66.7
	4 times and above	7	33.3
	Total	21	100.0

Awareness of human breast milk donation among the respondents

To explore the awareness of human breast milk donation among the participants, they were asked whether they had ever heard of mothers who donated their milk to be fed on another child other than their own. From the discussions with the participants, low awareness of human breast milk donation emerged as the dominant theme. Quantitatively, (54.3%) of the respondents indicated that they had never heard of mothers who donated milk to be fed on another mother’s child. Further, 75.8% of the respondents indicated that they had never seen a child or children who were fed on donated human milk. Similarly, a significant proportion (64.4%) of the respondents indicated that they had never heard of a human breast milk bank. This is illustrated by the following verbatim quotes;

--- I have never heard of anything about that. Are you sure that mothers can donate their own breast milk for other babies to take. Woah, that’s new to me. (Pa04)

I have never heard of it. I have heard it today as you were introducing it here. (Pb03)

I have never heard or even seen a mother donating her breast milk? I have never also seen a child being given human milk from someone else apart from their own mother. (Pb01)

I have never heard about it, all I know is that, for mothers that die or for whatever reason are not able to breastfeed their newborns, the newborns are given fresh cow milk. I am hearing of it for the first time here from you. (Pc03)

Willingness to donate human breast milk among the participants

To explore the willingness to donate human breast milk among the participants, they were asked whether they would be willing to donate their breast milk to a human milk bank. From the discussions with the participants, openness to donating one’s own breast milk emerged as the overarching theme with more than half (57.1%) of the respondents indicating their willingness to donate their breast milk to a human milk bank with most perceiving it as a noble cause. This was more so if they were requested to donate and if they had more breastmilk than their own child required. This is evidenced by the following quotes:

I would be willing to donate my breast milk if called upon, any time. (Pa04)

If I have more than enough for my baby, why not. I would give my own milk for use on other babies not able to receive it from their own mothers. (Pa06)

I too would be happy to offer my own breast for use by other babies. Why not, especially if I have more than my child requires…. (Pc02)

I think it is a noble cause. I would be happy to help in that way. (Pb06)

If I am healthy and have more than enough for my baby, I would gladly donate the excess milk. You never know, it could save a life of another child. (Pc07)

Willingness to use donated human breast milk on their babies

To assess the participants’ willingness to use donated human breast milk on their babies, they were asked whether they would allow their babies to use or be fed on donated human breast milk from other mothers, from a human milk bank. From the discussions with the participants, hesitancy to use donated human milk emerged as the dominant theme. A significant proportion (34.2%) of the mothers indicated that they would not allow their babies to be fed on donated human milk from a human milk bank due to discomfort and mistrust in the source of donated milk. Further the (65.8%) of the pregnant women who indicated willingness to allow their baby to be fed on donated human milk from a milk bank, had conditions. Only in specific circumstances would they allow their babies to be fed on donated breast milk. These included if they were very sick; if the doctor advised so; If they did not have enough milk for the baby and to a lesser extent if they were not available. This is evidenced by these quotes:

I think I would be very hesitant to allow my child to be fed with donated human milk. May be if I am very sick and cannot help it. (Pa03)

Personally, it is a no. Why would I allow my child to be offered breast milk from another woman? Honestly, I do not see that working with me. (Pb05)

That would only happen in very exceptional circumstances, such as if I was critically ill or I completely have no milk to breastfeed my baby. (Pa07)

For me, it would take a lot of persuasion to allow my child to be fed with breast milk from a human milk bank. It is hard to trust people, you know. So, I have my own reservations about it. (Pb04)

… it feel yack… almost nauseating. I would imagine my baby vomiting’ (Pc 12).

It was noted that the perceptions of mothers regarding the use of donated milk could be potentially shaped by the level of trust placed in medical personnel, whose professional authority and guidance were viewed as credible and reassuring.

As quoted, That would only happen… if the doctor advised. (Pa07)

Discussion

Awareness of human breast milk donation and milk banking among the respondents

This study revealed sub-optimal awareness of human breast milk donation and milk banking among the study participants. This concurred with [4] who in a study on human milk donation and banking in Kenya noted that there was low awareness of this concept among most of the women of child-bearing age in the country, with only 23% of the participants having heard of human milk banking (HMB). In China a study by [12] among postpartum women reported that only 20% of the respondents had prior knowledge of human milk banks and milk donation. Likewise, in their study [1], in Uganda reported that 50.2% of the interviewed women were found to be aware of human milk donation and HMB [4]. On the contrary [13] and [14], showed that there was lack of awareness amongst Muslim women regarding Muslim-friendly milk banks and thus there were negative perceptions and views about donating milk and also setting up milk banks. Though the current awareness level may have improved, studies point to the need to create more awareness on human breast milk donation and banking among potential mothers. A Ugandan study reported that over 77% of postnatal mothers expressed willingness to donate after learning about milk banking protocols and cultural safety, highlighting the need of targeted education on breastmilk donation and banking [1].

Willingness to donate human breast milk among the respondents

Findings from this study indicate that most of the respondents were willing to donate their breast milk for use by the babies in need of it. Some of the attributes that were associated with the willingness to donate included being educated on its importance and if there was a form of compensation. The findings agreed with those of [4] who established that majority (91%) of the surveyed mothers had a positive attitude towards donating their breast milk to a human milk bank. On a personal level, 79% were willing to donate the milk to a milk bank. Similarly, in studies by [15] in Nigeria exploring the acceptability of human breast milk donation among women of child bearing age, a significant proportion (62.1%) of the women showed willingness to donate their breast milk to human milk banks particularly if they had more than what their baby needed [16]. noted that, in most instances, mothers who donate their surplus milk to those newborns in need through human milk banks often do so freely to benefit others - they just feel good about helping another baby’s wellbeing. In contrast [17], reported low willingness to donate human breast milk among surveyed women in Eastern Ethiopia. Only 11% of the respondents were willing to donate their breast milk. In their study in China [12], revealed that only 23% were willing to donate their breast milk consistently. Likewise, a study by [18] in Ghana revealed that participants perceived donating human milk as strange and bizarre. They had different concerns in relation to donating their breast milk. While some feared disease transmission, others cited religious and others cited lack of information on the idea of milk banking.

Willingness to use donated human breast milk on their babies

Findings from this study revealed that there was general reluctance among participants towards use of donated human breast milk on their babies and also conditional willingness to use donated milk with most citing the advice of healthcare professionals. The role of the healthcare providers in influencing perceptions of use of donated human milk has been reported elsewhere [19]. Attributes found to have a negative association with willingness to use the donated milk included fear of disease transmission, fear of familial diseases, and out of personal dislike. The practice was viewed as unacceptable or unnatural, suggesting deep-seated cultural and emotional beliefs influencing attitudes toward the use of donor milk. These findings corroborated those of [4] who noted that though a majority (87%) of women would be willing to donate their breast milk for other babies in need, fewer (59%) would accept their babies to be fed with donated human milk from milk banks. Similar views were expressed by [17] who noted very low acceptability levels of use of donated human milk among mothers in Ethiopia, where only 15.2% would be willing to use the donated milk to feed their babies. Likewise, in China [12], also reported that a majority of surveyed postpartum women were more willing to provide milk rather than to receive it. In Iran [13], reported that shared breastmilk had cultural kinship implications among mothers who had low knowledge but high acceptability of human milk donation. However, only 3.8% of mothers reported that they would accept donated milk in the context of formula being expensive. This trend was also noted in USA where [20] revealed that mothers would choose formula milk over donated human milk. However mothers would prefer human milk donated from a relative or someone known to them [19, 20]. In contrast [9], reported that the majority (61.5%) of the mothers were willing to give the donated milk to their babies. A 2025 meta-synthesis of worldwide findings also emphasized the emotional and psychosocial aspects of milk donation, including maternal worry, discomfort with anonymity, and preference for known donors ([21]. This shows that the fear of the unknown is a factor in human milk donation that is yet to be explored. Studies elsewhere have reported cultural factors, distrust in people mothers do not know, religious reasons and other factors [13, 14] as reasons for fear of use of donated human milk. A study done among Ghanian women living in the USA described it as weird and unfamiliar in comparison to the more familiar wet nursing practice [19].

Some mothers expressed fear that another mother’s breastmilk could have infections, especially HIV. The fear of vertical transmission has also been reported in Busia, Kenya, among both mothers and medical personnel [22]. An in-depth understanding of the interplay of factors leading to this fear is necessary. It is important to note that this study focused on pregnant women, whose perceptions may differ once they have given birth and are faced with the experience of caring for an infant. It has been noted that women who had prior experience with the use of human donor milk had a positive attitude towards feeding their infants with it [19].

Limitations of the study

The limitations of this study included the possible social desirability bias encountered in the use of FGD [23, 24]. The participants may therefore have given socially desirable answers, considering that milk donation is a sensitive topic. In addition, as noted in FGD, dominant participants tend to overshadow the quieter participants ([24].

To mitigate the above limitations, research assistants, who were qualified nurses, were trained to have a non-judgmental posture and assure the participants that there was no wrong answer and that whatever they discussed was held in confidence as learnt from [23]. The research assistants were encouraged to prompt the quieter participants. The rigor of this study could be improved if one-on-one interviews were conducted, as the participants may have felt more comfortable expressing their opinions without fear of being judged by fellow participants. However, FGD remains feasible in exploring group perceptions on the use of donor milk.

Public health implications

Understanding and addressing the barriers to using human milk banking (HMB) is crucial for the successful implementation of the program, as its use is demand-driven. Involving all key stakeholders, including healthcare workers, relatives, community health workers, and peers, is essential to promote acceptance and ensure community support. Health education initiatives, preferably embedded as part of Antenatal and Postnatal care, would be a starting point in achieving buy-in. Transparency in HMB procedures, establishing feedback mechanisms, as well as monitoring use of HMB could contribute to addressing the negative perceptions by users.

Such engagement can help increase the use of donated human milk, improve infant nutrition, and reduce infant morbidity and mortality.

Conclusion and recommendation

There was low awareness of human breast milk donation among the study participants. Most of the pregnant women showed willingness to donate their breast milk for use by babies in need. However, most were less inclined to allow their babies to be fed with donated human milk safe for when extremely necessary or unavoidable. The practice on human milk donation was also low. Increased willingness to donate and use donated human breast milk could be achieved through greater awareness of human milk donation among mothers during antenatal clinics. The role of healthcare workers in influencing the perception of HMB can use cannot be overemphasized.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ERC

Ethics review committee

HMB

Human milk banking

KNH

Kenyatta national hospital

NACOSTI

National council of science, technology and innovation

PMH

Pumwani maternity hospital

UoN

University of Nairobi

WHO

World Health Organization

Author contributions

Conceptualization of the research and research design was done by JW, MK and LK. JW and FO, collected and analysed the data, while MK and LK validated the data analysis. All authors took part in drafting and revising the final manuscript.

Funding

The authors received no funding for this study.

Data availability

The data that support the findings are available from the authors upon reasonable request and with permission of UoN/KNH ERC.

Declarations

Ethics approval and consent to participate

The KNH-UoN Ethics and Research Committee (ERC) approved the study (Ref: KNH-ERC/A/484) while permission to undertake the study at PMH antenatal clinic was granted by the hospital’s management. Research permit was issued by NACOSTI (NACOSTI/P/23/30578). Participants gave informed consent and participated voluntarily. Obtained data were processed and reported anonymously.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.