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. 2018 Dec 27;14(Suppl 6):e12606. doi: 10.1111/mcn.12606

Psychosocial dimensions of human milk sharing

Ellen J Schafer 1,✉, Sato Ashida 2, Aunchalee EL Palmquist 3,4,*,✉
PMCID: PMC6866063  PMID: 30592166

Abstract

Breastfeeding is critical to maternal and infant health. Psychosocial factors are associated with lactation outcomes, and perinatal mood disorders (PMDs) are often linked with breastfeeding difficulties and early, unexpected weaning. Parents may utilize human milk sharing to ensure their infant receives human milk when breastfeeding requires supplementation or is not possible, but this practice carries health risks and is often stigmatized. Milk sharing recipient mothers may be particularly vulnerable to PMDs associated with breastfeeding difficulties. The study objective was to explore factors associated with emotional responses to a parent's decision to feed their infant with shared human milk. An online cross‐sectional survey of 205 milk sharing recipients was analysed with linear regression. Controlling for participants' education and breastfeeding difficulties, higher perceived social stigma was associated with more negative emotional responses (p < .01). Receiving strong spousal/partner support for milk sharing (p < .001) and screening donors regarding the health of their nursling(s) (p < .05) were associated with more positive emotional responses. Social stigmatization of milk sharing may negatively influence emotional responses among recipient mothers. Based on these results, it can be recommended that health professionals screen breastfeeding mothers with lactation difficulties for emotional distress that may lead to PMDs and provide evidence‐based information about milk sharing in a nonstigmatizing way. Health professionals may support informed decision‐making for infant feeding practices, including human milk sharing, by providing information on milk sharing risks and risk mitigation, developing evidence‐based practices and guidelines that facilitate safe milk sharing, and directing families to available resources for psychosocial support.

Keywords: human milk sharing, psychosocial factors, social stigma, social support

Key messages.

  • Breastfeeding mothers or parents who experience lactation difficulties often experience perinatal mood disorders, breastfeeding supplementation, undesired weaning, and consider peer‐to‐peer milk sharing as an infant feeding practice.

  • Parents who provide their children shared human milk may experience negative psychosocial impacts of social stigma, while strong spousal support for milk sharing and donor screening behaviour is associated with positive emotional responses.

  • Future prospective studies are needed to assess the prevalence of perinatal mood disorders among milk sharing recipient parents and the influence of psychosocial factors related to milk sharing on psychosocial well‐being.

1. INTRODUCTION

Recent intensification of breastfeeding promotion as a public health priority globally and in the United States (U.S.) has led to improvements in breastfeeding rates (Rollins et al., 2016; World Health Organization (WHO) & United Nations International Children's Emergency Fund (UNICEF), 2017); yet most mothers in the U.S. who initiate breastfeeding do not breastfeed as recommended by the World Health Organization (WHO, 2003) or the American Academy of Pediatrics (Centers for Disease Control and Prevention (CDC), 2016). There is a large population of predominantly White, college‐educated, middle‐income mothers in the U.S. who intend to breastfeed as recommended, initiate breastfeeding, and yet experience disrupted lactation, defined as early undesired weaning (Stuebe et al., 2014). Research has demonstrated that multiple spheres of influence shape disparate breastfeeding patterns and outcomes in the U.S., ranging from interactions between social structural factors to individual factors (Bentley, Dee, & Jensen, 2003; Tiedje et al., 2002). Among the key social structural factors that negatively impact breastfeeding outcomes are poor lactation support and management postpartum, lack of access to skilled lactation support, absence of paid parental leave policies, and weak support for breastfeeding in the workplace (Rollins et al., 2016; Steurer, 2017; Stuebe, 2014; Tully, Stuebe, & Verbiest, 2017; Victora et al., 2016).

Human lactation is complex and highly responsive to environmental influences, particularly those that impact the timing of breastfeeding initiation immediately postpartum, maternal and infant proximity, frequency and duration of breastfeeding bouts, effective management of lactation challenges, and support for maternal–infant well‐being (Stuart‐Macadam & Dettwyler, 1995; Tomori, Palmquist, & Quinn, In Press; Wambach & Riordan, 2015). A wide range of sociocultural factors, including breastfeeding stigma, a proliferation of formula marketing, weak spousal, family, and social support for breastfeeding as recommended, and cultural norms regarding infant feeding and care also influence breastfeeding practices and outcomes (Thomson, Ebisch‐Burton, & Flacking, 2015; Thulier & Mercer, 2009; Tomori et al., In Press). An experience with difficult lactation and breastfeeding challenges is commonly reported among U.S. breastfeeding mothers and is related to earlier than recommended complementary feeding and/or early undesired weaning (Stuebe et al., 2014). Specifically, breastfeeding pain, perinatal mood disorders (PMD), and perceived insufficient milk are associated with shorter periods of breastfeeding exclusivity birth–6 months and breastfeeding cessation (Gatti, 2008; Stuebe & Bonuck, 2011; Stuebe, Grewen, Pedersen, Propper, & Meltzer‐Brody, 2012; Wouk, Stuebe, & Meltzer‐Brody, 2017).

Human milk sharing in the U.S. is an infant feeding practice that commonly occurs within families, friendship networks, and community‐based social groups, often facilitated by online social networking (O'Sullivan, Geraghty, & Rasmussen, 2016; Palmquist & Doehler, 2016; Perrin et al., 2016; Reyes‐Foster, Carter, & Hinojosa, 2015). Increasingly, human milk sharing is also facilitated by health professionals in both clinical and nonclinical settings (O'Sullivan et al., 2016; Palmquist & Doehler, 2016). Parents in the U.S. have utilized human milk sharing to provide their infants with donated human milk, particularly when breastfeeding requires supplementation upon weaning (O'Sullivan, Geraghty, & Rasmussen, 2016; Palmquist & Doehler, 2014, 2016; Reyes‐Foster, Carter, & Hinojosa, 2015). One study found that most mothers in the U.S. who were milk sharing recipients were indeed breastfeeding mothers who had experienced self‐reported lactation insufficiency, and many of these mothers were highly motivated to breastfeed, as evidenced by their continued breastfeeding or expressing their own milk during the time they were seeking shared milk for their infants (Palmquist & Doehler, 2014). When compared with milk sharing donors, recipients reported higher rates of preterm and caesarean section birth, lower rates of breastfeeding support from spouses/partners, family, and employers, and weaker support for breastfeeding from paediatricians, all of which are associated with lower rates of breastfeeding as recommended for the general population of U.S. mothers (Palmquist & Doehler, 2014). Among the more common infant conditions reported by this population of mothers were tongue/lip tie (20.6%), failure to thrive (14.1%), breast refusal (11.6%), and food allergy/sensitivity (10.1%), whereas 42% of mothers reported no significant infant conditions related to their decision to feed their infant with shared milk (Palmquist & Doehler, 2016). Moreover, studies have revealed that many milk sharing mothers had experienced extremely difficult breastfeeding challenges, feelings of grief associated with lactation insufficiency, post‐partum depression, social stigma for breastfeeding, pressure to formula feed, and social stigma for using shared milk to feed their infants (Palmquist, 2015; Tomori, Palmquist, & Dowling, 2016). Together, these findings suggest that milk sharing recipients who have experienced challenges related to their experience with insufficient lactation may also face additional stressors, including complex social stigma for breastfeeding, formula refusal, and milk sharing, which may negatively impact their post‐partum psychosocial well‐being.

It has been demonstrated that many mothers have positive experiences in giving their milk, whether it be to a human milk bank or through milk sharing (Alencar & Seidl, 2009; Carroll et al., 2014; Gribble, 2014b; Perrin et al., 2016). Other studies have revealed that milk sharing recipients' experiences are often more complicated and reflect individual breastfeeding challenges, the closeness of the relationships that are formed through milk sharing, their infants' specific needs, and their level of concern about the potential risks of milk sharing (Gribble, 2014a, 2014c; Palmquist, 2015; Palmquist & Doehler, 2016). Yet, although the evidence for key aspects of milk sharing practices that intersect with public health considerations has grown, the psychosocial dimensions of milk sharing, particularly among mothers who have experienced lactation difficulties, have not been adequately explored. Therefore, the purpose of this study is to examine the relationship between milk sharing recipient parents' lactation difficulties, social support, social stigma, and their reported affective response to feeding their infants with shared human milk.

2. METHODS

Data for the present study were gathered through a one‐time cross‐sectional survey as one component of a multi‐year, mixed methods, multi‐sited ethnographic study of human milk sharing practices in the U.S. Data collection methods have been described previously (Palmquist & Doehler, 2014, 2016; Perrin et al., 2016; Tomori, Palmquist, & Dowling, 2016). Ethics approval for the study was granted by the Elon University Institutional Review Board.

2.1. Participants

Two hundred six participants from the U.S. who completed a self‐selected online survey indicated that they had been a milk sharing recipient, defined as having ever received human milk from a peer for infant feeding. One of these respondents was excluded due to extensive missing data needed to calculate the dependent variable. An additional respondent's survey was missing one item needed to calculate the dependent variable, which was imputed from the mean of the remaining sample. Thus, the present analyses include 205 participants.

2.2. Measures

2.2.1. Recipients' affective responses to milk sharing

Exploratory qualitative and ethnographic research of recipient parents' milk sharing experiences revealed a range of feelings regarding their decision to feed their infant with human milk obtained via peer‐to‐peer milk sharing (Palmquist, 2015; Tomori et al., 2016). These findings were used to develop survey items for measuring affective responses to milk sharing. Survey respondents were asked to indicate the frequency of positive and negative affective responses regarding their decision to feed donor human milk to their child using a 5‐point Likert scale ranging from 4 = always to 0 = never. Five of the nine items assessed the presence of positive affect (i.e., feeling empowered, relieved, happy, confident, and informed) and four items assessed the presence of negative affect (i.e., feeling sad or depressed, inadequate, anxious or worried, and confused).

In the present study, a mean summary measure of the positive and negative affect was calculated for each participant by summing the total positive and negative items, then dividing by the total number of items (e.g., mean positive = sum of positive items/5). The overall “netpositive” measure was calculated for each participant by subtracting the mean negative score from the mean positive score, such that the score could range from −4 to 4. This netpositive was used as the outcome of interest.

2.2.2. Breastfeeding difficulties

Participants indicated if they experienced any of 15 commonly reported breastfeeding difficulties during their most recent lactation (list of difficulties reported in Table 2). The sum of all breastfeeding conditions reported by recipients was calculated for inclusion in the models.

Table 2.

Emotions related to milk sharing, breastfeeding difficulties and milk sharing concerns

Frequency (%) Mean (SD), range
Emotions related to milk sharinga (N = 205)
Positive affect
Empowered 3.19 (1.10), 0.00–4.00
Relief 3.78 (0.54), 0.00–4.00
Happy 3.60 (0.73), 0.00–4.00
Confident 3.46 (0.89), 0.00–4.00
Informed 3.60 (0.65), 0.00–4.00
Mean positive affect 3.53 (0.61), 1.20–4.00
Negative affect
Sad 1.01 (1.07), 0.00–4.00
Inadequate 0.86 (0.97), 0.00–4.00
Anxious 0.86 (0.97), 0.00–4.00
Confused 0.29 (0.60), 0.00–3.00
Mean negative affect 0.96 (0.80), 0.00–3.75
Netpositive (N = 205, outcome) 2.57 (1.23), −2.15‐4.00
Breastfeeding difficulties (N = 205)
Blocked or plugged ducts 65 (31.71)
Breast abscess 5 (2.44)
Cracked or bleeding nipples 64 (31.22)
Dysphoric milk ejection reflex (D‐MER) 4 (1.95)
Inverted nipples 11 (5.37)
Insufficient glandular tissue (IGT) 40 (19.51)
Low milk supply 140 (68.29)
Long‐term medications incompatible with breastfeeding 4 (1.95)
Mastitis 27 (13.17)
Nipple infection 13 (6.24)
Overactive milk ejection reflex 12 (5.85)
Pain with breastfeeding 55 (26.83)
Reynaud's syndrome 16 (7.80)
Vasospasm 18 (8.78)
Yeast infection 31 (15.12)
Sum of breastfeeding difficulties (N = 205) 2.46 (1.78), 0–10
Health risk concernsb
Disease transmission (N = 198) 1.64 (1.02), 0–3
Exposure to pharmaceuticals (N = 200) 1.95 (0.93), 0–3
Exposure to nicotine (N = 199) 1.95 (1.04), 0–3
Exposure to alcohol (N = 201) 1.81 (1.03), 0–3
Exposure to environmental toxins (N = 201) 1.50 (0.98), 0–3
Exposure to dietary allergens (N = 194) 1.20 (1.02), 0–3
Mean health risk (N = 185) 1.67 (0.76), 0–3
Social stigma concernsb
Negative social stigma (N = 203) 0.67 (0.81), 0–3
Negative family stigma (N = 203) 0.72 (0.86), 0–3
Mean social stigma (N = 202) 0.69 (0.80), 0–3
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a

The value of the Likert scale items were measured such that 0 = never, 1 = rarely, 2 = half of the time, 3 = most of the time, 4 = always.

b

The value of the Likert scale items were measured such that 0 = no concern, 1 = very little concern, 2 = some concern, 3 = extreme concern.

2.2.3. Milk sharing concerns

Participants were asked to consider potential health risks, including disease transmission and exposure to nicotine, pharmaceuticals, alcohol, environmental toxins, and dietary allergens, which were drawn from the public health literature (United States Food and Drug Administration (FDA), 2010; Gribble & Hausman, 2012; Keim et al., 2013) and exploratory research (Palmquist, 2015; Palmquist & Doehler, 2016). They indicated their degree of concern regarding each of these six items on a 4‐point Likert scale ranging from 0 = no concern to 3 = extreme concern. The average health risk concern was calculated for each participant by summing the response and dividing by six.

Participants also indicated their perceived social risks of milk sharing (Tomori et al., 2016) by rating their concern about negative social stigma and negative family stigma on the same 4‐point Likert scale. An average measure of social stigma related to milk sharing was calculated as the mean of concern between negative social and negative family stigmas.

2.2.4. Social support for milk sharing

Participants reported the strength of social support for milk sharing that they received from a spouse/partner, family, friends, and online social networks using a 5‐point Likert scale, ranging from 0 = no support to 4 = strong support. These measures were dichotomized to indicate the presence or absence of strong support for each category.

2.2.5. Screening behaviours

Participants reported the frequency with which they asked milk sharing donors to provide information about six items (e.g., diet and nutrition, health of nursling) on a 5‐point Likert scale (4 = always to 0 = never). A complete list of items can be found in Table 3. Each of the items was dichotomized to indicate screening for the item always or most of the time versus half of the time, rarely, or never and used independently in the analyses.

Table 3.

Social support and screening behaviours

Frequency (%)
Strong milk sharing supporta
Spouse/partner (N = 200) 163 (81.50)
Family (N = 193) 63 (32.64)
Friends (N = 191) 88 (46.07)
Online social networks (N = 191) 142 (74.35)
Screen donorsb
Health status of nursling (N = 196) 80 (40.82)
Mental health history (N = 190) 10 (5.26)
Age of nursling (N = 193) 111 (57.51)
Diet and nutrition (N = 196) 110 (56.12)
Substance use (tobacco, alcohol, illegal drugs, caffeine, herbs, N = 180) 149 (82.78)
Physical activity (N = 195) 16 (8.21)
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a

Versus not strong support.

b

Always or some of the time versus half of the time, rarely, or never.

2.2.6. Demographic covariates

Sociodemographic factors including participant age in years, race (non‐Hispanic White versus any other race), education (at least a college education versus any other education level), employment status (employed full or part time versus not employed), marital status (married or living as married versus any other status), household income (above versus at or below the sample median), and household size (continuous) were considered as possible covariates in analysis.

2.2.7. Analyses

Descriptive statistics of the variables representing key study factors were evaluated. Linear regression models were used to explore netpositive affect of deciding to feed their infant with human milk obtained through milk sharing. Unstandardized coefficients and standard errors are reported. A full multivariable model was created by including the factors that were associated with the outcome in bivariate evaluations at the p < .10 level of significance.

3. RESULTS

3.1. Participant description

Most participants self‐identified as non‐Hispanic White (95%), at least college educated (63%), employed full or part time (54%), married or living as married (88%), and living at or below the median sample household income of $55,000–59,999/year (51%). On average, participants were 31–32 years old and lived with about four people in their home (Table 1).

Table 1.

Participant demographics (N = 205)

Mean (SD), range Frequency (%)
Age 31.57 (5.61), 21–58
Non‐Hispanic Whitea (N = 194) 185 (95.36)
College education or moreb 130 (63.41)
Employed full or part timec 111 (54.15)
Married or living as marriedd (N = 110) 97 (88.18)
Household income, more than mediane (N = 202) 99 (49.01)
Household size (N = 200) 4.01 (1.32), 2–10
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a

Versus any other race.

b

Versus less than a college education.

c

Versus any other employment status.

d

Versus any other marital status.

e

Versus median income or less, median: $55,000–59,999.

3.2. Emotional responses to milk sharing

As shown in Table 2, participants reported the presence of both positive and negative affect. Overall mean for the five positive affect items was 3.53 (SD = 0.61, range 1.20–4.00), indicating participants generally felt positive emotions related to milk sharing between most of the time and always. The overall mean for the four negative affect items was 0.96 (SD = 0.80, range − 2.15–4.00), indicating participants generally felt negative emotions related to milk sharing between never and rarely. In terms of netpositive, scores averaged 2.57 (SD = 1.23, range − 2.15 to 4.00) and only 6% of participants had scores <0; thus, participants generally reported more positive affect regarding their decision than negative. In bivariate analysis, the only demographic covariate significantly associated with netpositive affect regarding the decision to feed shared milk was the level of participant education. Having at least a college‐level education was associated with a significant decrease in overall netpositive (p < .01), indicating mothers with at least a college education were likely to have lower netpositive scores, compared with mothers with less than a college education. Education was carried through as a covariate in the subsequent multivariable model.

3.3. Breastfeeding difficulties

As shown in Table 2, participants faced a range of breastfeeding difficulties with their most recent lactation, identifying, on average, two (range 0 to 10) out of a possible 15 difficulties. In bivariate analysis, the sum of breastfeeding difficulties was associated with a decrease in netpositive affect (p < .10).

3.4. Milk sharing concerns

There was also some concern regarding the exposure to substances that may be present in shared milk, with an overall average health risk concern between some and very little (mean = 1.67, SD = 0.76); however, mean perceived health risk was not significantly associated with the netpositive outcome. Negative social and family stigma presented, on average, between very little and no concern to participants (mean = 0.69, SD = 0.80). In bivariate analysis, concern about negative social stigma was significantly associated with a decrease in netpositive affect regarding the decision to feed shared milk (p < .01) and was carried through in the multivariable model.

3.5. Social support for milk sharing

As shown in Table 3, majority of participants indicated receiving strong social support for milk sharing from a spouse/partner (82%) and online social networks (74%). In bivariate analysis, strong spousal/partner support was most strongly associated with an increase in overall netpositive affect regarding the decision to feed shared human milk (p < .001). Strong support from family (p < .05) and online social networks (p < .05) were also initially significant in bivariate analysis; however, when considered together with strong spousal support, only spousal support remained significantly associated with netpositive and was carried forward in the multivariable model.

3.6. Screening behaviours

Although most mothers reported asking donors screening questions (always or some of the time) about the age of their nursling (58%), diet (56%), and donors' use of substances that may be found in milk (i.e., tobacco, alcohol, illegal drugs, caffeine, and herbal galactagogues; 83%), only 41% indicated screening for the health status of the donor's nursling (see Table 3). Asking screening questions about the health status of the donor's nursling, always or some of the time, was the only screening behaviour associated with netpositive affect, an increase (p < .10), and carried forward in the multivariable model.

3.7. Multivariable model

In the progression of building the multivariable model shown in Table 4, education was entered as the covariate with breastfeeding difficulties and milk sharing concerns of negative stigma (Model 1). Sum of breastfeeding difficulties (p < .05) and mean concern regarding negative social stigma (p < .001) remained associated with a lower overall netpositive. With the addition of strong spousal support for milk sharing and donor screening regarding the health of the nursling, the final model is presented in Model 2. Controlling for education and breastfeeding difficulties, mean concern about negative social stigma (p < .01) was associated with lower overall netpositive, whereas strong spousal support for milk sharing (p < .001) and screening donors regarding the health of their nurslings (p < .05) were associated with higher overall netpositive affect regarding the decision to feed shared human milk.

Table 4.

Multivariable models

Crude (bivariate) associations B (SE)a Model 1 (N = 202) B (SE) Model 2 (N = 188) B (SE)
Demographics
College education or moreb −0.55 (0.18)*** −0.57 (0.17)*** −0.49 (0.17)**
Difficulties/concerns
Sum of breastfeeding difficulties −0.09 (0.05)* −0.09 (0.05)** −0.07 (0.04)
Mean social stigma −0.37 (0.11)*** −0.36 (0.10)**** −0.33 (0.10)***
Social factors
Strong spousal support for milk sharingc 1.07 (0.21)**** 0.88 (0.22)****
Screening: Health of nurslingd 0.33 (0.18)* 0.36 (0.16)**
Model fit
R 2 ‐‐ 0.12 0.23
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a

Only the crude associations significant in bivariate analyses are presented.

b

Versus less than a college education.

c

Versus not strong support.

d

Always or some of the time versus half of the time, rarely, or never.

*

p < .10,

**

p < .05,

***

p < .01,

****

p < .001.

4. DISCUSSION

Lactation insufficiency has emerged as a critically important factor underlying the steady demand for human milk within milk sharing communities, at least within the U.S. (O'Sullivan et al., 2016; Palmquist, 2015; Palmquist & Doehler, 2014; Perrin, Goodell, Allen, & Fogleman, 2014; Reyes‐Foster et al., 2015; Tomori et al., 2016). Lactation difficulties, particularly those that may lead to a need for breastfeeding supplementation or early undesired weaning, are associated with an increased risk of PMDs in the general population (Stuebe et al., 2014). Consistent with such evidence, the prevalence of self‐reported postnatal depression in the general medical history of the present sample of milk sharing recipient mothers was 30.2% (60/205). Furthermore, among milk sharing recipient mothers and parents, disrupted lactation has been described as an experience characterized by intense grief and loss, which often goes unrecognized, dismissed, or unsupported by family, friends, and health care providers; these experiences are often circumscribed by overt social stigma of breastfeeding and milk sharing (Tomori et al., 2016). Stigma is often accompanied by social isolation, which introduces barriers to key networks of support that may strengthen mothers' and infants' resilience to postnatal stressors, including but not limited to those related to infant feeding (Olson, Holtslander, & Bowen, 2014). Milk sharing recipients carry an additional burden of navigating the various possible risks to their infants, particularly exposure to disease, harmful substances, and microbial contamination, commonly without adequate support from primary health care providers (O'Sullivan et al., 2016; Perrin et al., 2016). Given the confluence of possible postnatal stressors that milk sharing recipients may face, the goal of the present study was to explore the psychosocial context of lactation on milk sharing recipients' affective response to feeding their infants with shared milk. In other words, how did milk sharing recipient parents feel about their decision to feed their infant with shared human milk, and what individual lactation and social factors are associated with these positive or negative feelings?

In the public health literature and popular media, milk sharing has been framed as a dangerous infant feeding practice (Carter & Reyes‐Foster, 2016; Carter, Reyes‐Foster, & Rogers, 2015; Geraghty, Heier, & Rasmussen, 2011; Jones, 2013; Keim et al., 2013, 2014; Landers & Hartmann, 2013; Nelson, 2012). Due to potential safety, disease, and exposure concerns regarding the use of nonpasteurized donor milk, parents have been cautioned by the FDA and AAP against feeding their infants with milk obtained through milk sharing (American Academy of Pediatrics, 2016; FDA, 2010; Gribble & Hausman, 2012). These risk messages play a role in the ways that families who decide to practice milk sharing navigate their experiences, and in particular, the resulting social stigma that surrounds milk sharing (Tomori et al., 2016). In response, milk sharing recipients tend to screen their donors in a way that is consistent with their perceptions of various types of milk sharing risks (Gribble, 2014c; Palmquist & Doehler, 2016). When perceived social stigma for milk sharing is high, however, parents use a variety of strategies to avoid the negative impacts of this stigma. For example, parents may selectively disclose information about their infant feeding practices to those they perceive as stigmatizing agents, particularly family members, friends, and health care providers (Tomori et al., 2016). Similarly, when social support for milk sharing is high and stigma is low, many parents report feeling empowered to make informed milk sharing decisions, to ask relevant questions of donors in mitigating the potential risks of milk sharing, and viewing milk sharing as a social means of coping with lactation insufficiency (Gribble, 2014c; Tomori et al., 2016).

Findings of the present study provide a quantitative assessment of the relationship between lower social stigma, greater social support for milk sharing, and recipient parents' positive affect, an aggregate measure of feeling empowered, relieved, happy, confident, and informed. Whereas social stigma is isolating and is associated with less support within social networks, reduced social stigma may provide opportunities for expanding support. Parents who cope with lactation insufficiency by feeding their infants with shared milk but are unable to access social resources for psychosocial support, may face negative feelings regarding this infant feeding decision, including feeling sad or depressed, inadequate, anxious or worried, and confused. These affective responses may lead to PMD. Negative affect may be exacerbated among more highly educated mothers in this study population, perhaps because more mothers within this demographic are breastfeeding as recommended, and so those who do not may experience social pressure and stigma associated with unexpected and undesired supplemental feeding, formula feeding, or early weaning (Stuebe et al., 2014; Tomori et al., 2016). Without access to skilled lactation support to address complex breastfeeding challenges, an evidence‐based with which to navigate the plethora of potential risks of peer‐to‐peer milk sharing, and resources with which to cope with the grief and loss of breastfeeding that many milk sharing recipients face, breastfeeding parents who feed their infants with shared milk may be at risk for increased psychosocial distress.

Health care providers must support the psychosocial well‐being of milk sharing recipient parents and infants, and they may do this by providing nonstigmatizing, evidence‐based information about infant feeding alternatives, including human milk sharing (Gribble, 2012; Gribble & Hausman, 2012) to support informed decision‐making. Milk sharing parents, particularly those who are breastfeeding and facing lactation insufficiency, may benefit from screening for PMD and coordinated mental health and social support services in conjunction with skilled lactation care. Prospective studies assessing the prevalence of PMDs among milk sharing recipient parents, as well as the influence of milk sharing practice on psychosocial well‐being, are needed. Developing strong measures to quantify the relationship between infant feeding stigma and maternal and infant psychosocial outcomes is also an important avenue of future human lactation research.

5. LIMITATIONS

This study was cross‐sectional, and participants were a self‐selecting group of respondents to an online survey. All information regarding breastfeeding difficulties and maternal lactation issues were self‐reported and not weighted based on level of pain or importance.

6. CONCLUSION

The present study is the first to assess the potential negative outcomes of social stigma and weak social support on milk sharing recipient parents' affective response to seeking shared human milk for infant feeding. As anticipated, participants' concern regarding the risk of social stigma of milk sharing was negatively associated with affect and strong partner/spousal support for milk sharing and screening the health status of the donor's nursling were positively associated. Given the importance of strong spousal/partner support, health professionals may consider the value of screening breastfeeding mothers and parents for the types of social support they are receiving and from whom. These quantitative findings provide insight to the social factors associated with maternal affect regarding milk sharing, and more generally, infant feeding. Practitioners are in a unique position to support mothers and families who may be considering or participating in human milk sharing through anticipatory guidance for screening of donors, providing a safe, nonstigmatizing environment in which to openly address infant feeding issues, and referring families to additional community resources, as necessary (e.g., mental health services and lactation care). Developing validated measures to quantify infant feeding stigma and psychological outcomes are necessary to further inform research and interventions. Additionally, given the high proportion of participants who included postpartum depression in their medical history, future research should include prospective studies among milk sharing recipients regarding the prevalence of mood disorders and the association of milk sharing practice on maternal well‐being.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS

ES conducted the analysis and assisted in researching and writing the manuscript. SA provided detailed assistance with the study design and analysis and article preparation. AP is the principal investigator, conceived of the study, conducted the online survey, assisted with study and analysis design, and was instrumental in writing the manuscript.

ACKNOWLEDGEMENTS

The authors would like to thank the survey respondents for their generous contribution to this study.

Schafer EJ, Ashida S, Palmquist AEL. Psychosocial dimensions of human milk sharing. Matern Child Nutr. 2018;14(S6):e12606 10.1111/mcn.12606

Contributor Information

Ellen J. Schafer, Email: ellenschafer@boisestate.edu.

Aunchalee E.L. Palmquist, Email: apalmquist@unc.edu.

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