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Abstract

Background:

Human milk bank is a sustainable source of donor human milk (DHM) which is an acceptable alternative to the mother’s milk and it is not routinely available in Nigeria, a multi-ethnically diverse country.

The study aimed to assess the willingness to donate or accept human milk among pregnant women and mothers attending the antenatal, immunization, outpatient, under-five, and neonatal follow-up clinics in selected health facilities in Ekiti State, Southwest Nigeria.

Study Design and Methods:

A descriptive cross-sectional, mixed methods study design was used to collect data in selected health facilities in Ekiti State. Questionnaires and focus group discussions were used to collect quantitative and qualitative data respectively while data analysis was done using the IBM® Statistical Package for Social Science SPSS version 26® and thematic analysis respectively.

Results:

Of the 798 respondents, 529 (66.3%) and 626 (78.4%) did not know about wet nursing or human milk banking (HMB) respectively and 139 (17.4%) were willing to donate their breastmilk for a stipend. In the focus group discussion, 50% had heard about wet nursing but none heard about HMB. Maternal educational level had a significant impact on their willingness to donate or accept DHM (p < 0.00). Wholesomeness, cultural, and religious biases were major reasons affecting HMB acceptability.

Conclusions:

Awareness and perception of HMB are poor. Appropriate information, education, and counselling on HMB are needed to drive the adoption and establishment of HMB in Nigeria.

Keywords

Human milk banking mixed methods study donor human milk acceptability willingness

Introduction

Mothers’ own milk (MOM) is the best nutrition option for infants, but when unavailable, donor human milk (DHM) can be a suitable alternative. Donor human milk is collected, screened, pasteurized, and stored breast milk from a human milk bank. Although widely accepted in developed countries, DHM’s acceptability and uptake in sub-Saharan Africa, including South Africa and Kenya, remain low.^1,2 The American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recognize DHM as an acceptable alternative to MOM.^3,4

Fear of disease transmission, cultural, and religious prohibitions as well as concerns about the inadequacy of MOM for the babies of donors, affect the acceptability of human milk banking (HMB).^5–7 In addition, the variance between the willingness to donate compared with the willingness to accept with a preponderance towards donating has been reported.⁵

Human milk banking has been shown to improve breastfeeding rates in settings where it is practiced and decrease rates of necrotizing enterocolitis (NEC). However, in Nigeria, where exclusive breastfeeding rates are low, knowledge about HMB remains low, and the practice is not yet available for routine use.^8–11 A study conducted in the country over two decades ago found a wide gap in the willingness to donate or accept donor human milk (DHM), and more recent research revealed that knowledge about HMB remains low.^5,12 To improve the breastfeeding rates in Nigeria and increase the availability of DHM, surveys should be conducted in all geopolitical zones of the country to understand the factors that affect the acceptability of HMB.

This study aims to assess the willingness to donate or accept human milk and knowledge about human milk banking among pregnant women and mothers attending clinics in Ekiti State, Nigeria. The results will guide policies towards establishing human milk banks in the Southwestern region of the country.

Methods

Study design: The study was a mixed-methods descriptive cross-sectional design using quantitative and qualitative data collection methods which was carried out between June to December, 2021.

Study sites: The antenatal, immunization, under-five, and neonatal follow-up Clinics as well as the postnatal ward and special care baby unit of Ekiti State Teaching Hospital, State Hospital Ikere-Ekiti and eight Comprehensive and Primary Health Care Centres across the three Senatorial Districts of Ekiti State. These hospitals do not have access to or prescribe DHM at the present. Ekiti State is one of the States in Southwest Nigeria (Ekiti State Website, 2023).¹³

Target population: Pregnant women and post-partum and nursing mothers of children aged 2 years and below.

Inclusion criteria

Women at least 18 years of age

Pregnant women attending antenatal clinics in these facilities

Mothers attending immunization, or under-five clinics

Mothers at the Postnatal and Neonatal units

Exclusion criteria

Pregnant women whose foetus are not viable or with doubtful viability.

Women with postpartum haemorrhage or severe complications that were too ill to participate in the study.

Women with postpartum depression or severe mental health conditions.

Women who do not consent to the study.

Sample size

Sample size was calculated using the formula¹⁴:

n = \frac{Z^{2} P (1 - P)}{d^{2}}

n = \frac{{1.96}^{2} X 0.39 (1 - 0.39)}{{0.05}^{2}}

n = 366

where n = minimum sample size,

Z = standard normal variate at 95% CI is 1.96.

P = expected prevalence [39%],¹²

d = precision, allowable error margin of 5%.

Data collection: Quantitative data was accessed using a questionnaire designed by the researchers adapted from existing literature^15,16 in three major sections. Section one was on sociodemographic characteristics of the respondents including the age, place of residence, religious affiliation, ethnicity, and educational, and occupational details of the respondents and their spouses. The second section captured the details of the health care services that have been and are being patronized by the respondent. The third section caters to the respondent’s perception, knowledge, attitude, and practice (anticipated) towards HMB services. Qualitative data through focus group discussions (FGD) was collected from six consenting mothers in the neonatal ward, immunization clinic, and the out-patient department of three out of the 10 hospitals; discussing awareness of HMB, importance, willingness to donate human milk and acceptability of using donated milk. FGD sessions lasted about an hour and were conducted in English and Yoruba languages.

Ethical consideration: Ethical approval for the study was obtained from the Teaching Hospital ethical review committee. Written informed consent was also obtained from the respondents after due counselling on the study. Refusal of consent to participate in the study did not in any way interfere with the services patronized.

Data collection and analysis: The Quantitative data was collected using questionnaires administered by self-and/or trained research assistants and analysed using a statistical software. The sociodemographic characteristics and patronized health services of respondents were presented as frequencies and percentages. These were cross-tabulated with the perception, knowledge, attitude, and practice of the respondents, and associations determined using the chi-square and statistical significance were set at p < 0.05. Respondents with grossly missing information were excluded from the data analysis.

The qualitative data obtained from the FGDs were transcribed verbatim, translated into English as needed and analysed based on the themes.

Results

Of the 820 questionnaires administered to the mothers, 798 had complete responses and were analysed giving a response rate of 97.3%. The majority (73.6%) were aged 20–34 years, of the Christian religion (91.1%), from the Yoruba tribe (86.7%), had post-secondary education (62.8%), and were married (93.9%). Two-thirds and a third of the respondents patronized the infant welfare/immunization clinic and antenatal clinic respectively. Other socio-demographic characteristics of the respondents are shown in Table 1.

Table 1.

Sociodemographic characteristics of the respondents and Health Services Patronized.

Variable	Category	Frequency	Percentage (%)
Age (years)	<20	17	2.1
	20–34	587	73.6
	≥35	194	24.3
Religion	Christianity	727	91.1
Religion	Islam	71	8.9
Ethnicity	Yoruba	692	86.7
	Igbo	44	5.5
	Hausa	7	0.9
	Others	55	6.9
Educational level	No formal education – Uncompleted secondary education	59	7.4
	Completed secondary education	238	29.8
	Post-secondary education	501	62.8
Occupation	Unemployed	39	4.9
	Unskilled	285	35.7
	Semi-skilled	401	50.3
	Skilled	73	9.1
Marital status	Single	44	5.5
	Married	749	93.9
	Others^a	5	0.6
Partners’ educational status	No formal education – Uncompleted secondary education	58	7.3
	Completed secondary education	183	22.9
	Post-secondary education	557	69.8
Partners’ occupation	Unemployed	33	4.1
	Unskilled	240	30.1
	Semi-skilled	421	52.8
	Skilled	104	13.0
Health service patronized^b	Use ANC	252	27.5
	Use SCBU	29	3.2
	Use infant welfare or immunization	597	65.0
	Use OPD	24	2.6
	Use family planning clinic	16	1.7

Divorced/cohabiting.

Some individuals used multiple facilities.

Table 2 shows the obstetrics and breastfeeding history. Seven hundred and sixty (95.2%) of the mothers had at least a parous experience. Of these, 719 (94.6%) had antenatal care (ANC) in the immediate past pregnancy and the majority 641 (89.2%) had adequate ANC visits, had last delivery in a healthcare facility 608 (80.0%), and were counselled on breastfeeding 631 (87.8%). Most of the mothers 621 (81.7%) delivered per vagina but only 327 (43.0%) had postnatal clinic attendance which was inadequate in over 80% of this population but the majority of them had breastfeeding counselling. Exclusive breastfeeding was practiced by 560 (73.7%) of the participants while only 388 (69.3%) claimed to have breastfed exclusively for 6 months and 648 (85.3%) were still breastfeeding at the time of the study. Of the women who had patronized the different paediatrics-related health services, breastfeeding counselling was offered at the outpatient department and immunization clinic to 115 (75.2%) and 585 (77.0%) of the participants respectively. Of the 760 mothers, 391 (51.4%) had previous breastfeeding challenges; with delayed milk flow 171 (43.7%) and ‘not enough milk’ 138 (35.3%) being the most common challenges. Of those with ‘not enough milk’, alternative ‘feeds’ given were infant formula 41 (29.7%), corn gruel 30 (21.5%), water 21 (15.2%), adult milk 8 (5.8%), and other preparations including juice and herbal concoction 38 (27.5%). Among the women with breastfeeding challenges, about half 189 (48.2%) did not consult anyone for advice on how to solve the challenge, and about a quarter 97 (24.8%) consulted relatives including the baby’s grandmothers and friends, 90 (23.0%) consulted healthcare workers while the remaining 15 (3.8%) sourced for solutions from other sources.

Table 2.

Obstetrics and breastfeeding history of the respondents.

Variable	Category	Frequency	Percentage (%)
Parity	Nulliparous	38	4.8
	Primiparous	243	30.5
	Multiparous	486	60.9
	Grand Multiparous	31	3.9
ANC use in immediate past pregnancy(N = 760)^a	Yes	719	94.6
ANC use in immediate past pregnancy(N = 760)^a	No	41	5.4
Number of ANC visits (N = 719)	<4 visits	78	10.8
Number of ANC visits (N = 719)	≥4 visits	641	89.2
Place of ANC (N = 719)	None/Mission/TBA	59	8.2
	Health centres	230	32.0
	Private hospitals	119	16.6
	State/Specialist Hospitals	311	43.3
Counselling on breastfeeding during ANC (N = 719)	Yes	631	87.8
Counselling on breastfeeding during ANC (N = 719)	No	88	12.2
Place of last delivery (N = 760)^a	None/Mission/TBA	152	20.0
	Health centres	154	20.3
	Private hospitals	126	16.5
	State/Specialist Hospital	328	43.2
Mode of delivery of last baby (N = 760) ^a	SVD	621	81.7
	Elective	69	9.1
	Emergency	70	9.2
Postnatal care attendance (N = 760) ^a	Yes	326	42.9
Postnatal care attendance (N = 760) ^a	No	434	57.1
Number of Postnatal care (N = 760) ^a	≥4 visits	61	8.0
Number of Postnatal care (N = 760) ^a	<4 visits	699	92.0
Breastfeeding counselling during Postnatal care (N = 760) ^a	Yes	312	41.1
	No	448	58.9
Post-delivery Mother-baby separation (N = 760) ^a	Yes	127	16.7
Post-delivery Mother-baby separation (N = 760) ^a	No	633	83.3
Exclusive breastfeeding of last baby (N = 760) ^a	Yes	560	73.7
Exclusive breastfeeding of last baby (N = 760) ^a	No	200	26.3
Duration of exclusive breastfeeding of the last baby (N = 560) ^b	6 months	388	69.3
	<6 months	172	30.7
Currently, breastfeeding? (N = 760)	Yes	648	85.3
Currently, breastfeeding? (N = 760)	No	112	14.7
Age of child being breastfed? (N = 648)	<6 months	401	61.9
	6 months–1 year	182	28.1
	>1 year	65	10.0
A previous visit to COPD (N = 760)	Yes	153	20.1
A previous visit to COPD (N = 760)	No	607	79.9
Breastfeeding counselling during COPD visit (N = 153)	Yes	115	75.2
Breastfeeding counselling during COPD visit (N = 153)	No	38	24.8
Breastfeeding counselling during immunization clinic visits (N = 760)	Yes	585	77.0
	No	175	23.0
Previous breastfeeding challenge (N = 760)	Yes	391	51.4
Previous breastfeeding challenge (N = 760)	No	369	48.6
Type of breastfeeding Challenge (N = 391)	Delay milk flow	171	43.7
	Not producing enough	138	35.3
	Sore/Cracked nipple	69	17.6
	Others	13	3.3

ANC: Antenatal Clinic; PNC: Postnatal Clinic; COPD: Children outpatient department.

Nulliparous women were excluded.

Multiple responses.

Awareness about HMB

Knowledge of wet nursing was observed to be poor among the 798 study participants as 529 (66.3%) of them did not know about wet nursing and a higher percentage (78.4%) had never heard about HMB. Of the 172 respondents who had heard about HMB, 37.8% and 47.5% heard from the electronic media and healthcare workers (HCW) respectively (Doctors – 10%; Nurses – 12%; Nutritionists/Dietician – 7%; Other HCW – 28%).

Almost all the participants in the FGDs had not heard about HMB, however, about half of them knew about wet nursing. A 24-year-old mother replied ‘You people have come again o. What do you mean by breast milk banking? I have never heard about it. I only know that in the olden days, women used to breastfeed another child in the family if the mother is not around. Which one is breast milk banking again?’ Interactions with the mothers during the FGDs revealed that the practice of wet nursing was no longer widely practiced or acceptable by the mothers.

Opinions and concerns about HMB

More than half of the participants of the quantitative survey felt that HMB was not a good idea. More than half (58.5%) of the respondents felt that HMB is not a good idea, only 24.2% believe it is a good idea while 17.3% don’t know.

Most of the participants of the FGDs did not like the idea of HMB. One of the participants asked – ‘How will you collect breastmilk from a woman and store it? Will she express from home? How are you sure it is her milk? Will it not get spoilt? How will it be preserved? For how long can it be stored?’ ‘It looks odd/ strange to me’, said another 24-year-old mother of one.” ‘Another mother retorted, with the incessant power outages, how will the milk be preserved without it getting spoilt?’

Willingness to donate breast milk

Only 223 (27.9%) of the 798 participants were willing to donate their breastmilk for another baby’s use while 575 (72.1%) were not willing to donate their milk.

Most of the participants in the FGDs, 14 (77.8%), were also not willing to donate their breast milk while the remaining four (22.2%) do not mind if they had more than enough. A 27-year-old woman said, ‘I cannot donate my breast milk even if I have more than enough. The world is dangerous now, in this age of money-making rituals, why should I donate my milk, it can be used for money rituals. I will rather prefer to breastfeed the child if they bring him/ her but I cannot donate my milk for someone to take it away’. Another 26-year-old mother said: ‘I can donate my breastmilk to assist another baby if I have more than enough for my baby, however, I don’t think I have enough for my own baby’.

Reasons for willingness to donate breast milk

Of those who were willing to donate, reasons for willingness to donate were to help other babies in need (52.5%), for health promotion and disease prevention 28.3% (Table 3). The mothers who indicated their willingness to donate their breast milk during the FGDs said it is in their bid to help another baby in need. One of the mothers said, ‘breastmilk is good for every baby, hence her reason for her willingness to donate her milk if she has excess’. Another mother said, ‘breast milk has lots of benefits to babies and infant formula is very expensive, so for these reasons I will be willing to be of help to babies who need such help provided I have excess milk that my baby does not need’.

Table 3.

Reasons for willingness/unwillingness to donate breast milk.

Reasons	Frequency	Percentage (%)
Willingness to donate breast milk (N = 223)
To help other babies in need	117	52.5
Health promotion, growth, and disease prevention	63	28.3
Help other mothers in need	12	5.4
Alternative feeds (BMS) are expensive	17	7.6
Breastmilk is the best milk	6	2.7
Because I have excess milk	8	3.6
Unwillingness to donate breast milk (N = 575)
I don’t have enough	82	14.3
I don’t like the idea; it is not right	359	62.4
My spouse/family will not support it	79	13.7
It’s against our cultural and religious beliefs and will not be accepted	16	2.8
My breast will sag faster	15	2.6
It is unhygienic and can transmit disease	24	4.2

Reasons for being unwilling to donate breastmilk

Among those unwilling to donate their milk, 359 (62.4%) did not like the idea of milk donation and felt it was not right, 82 (14.3%) believed they did not have enough, 79 (13.7%) believed that their family or spouse would not support it while 4.2% felt that it is unhygienic and could transmit diseases (Table 3).

Most of the participants during the FGDs gave reasons similar to the findings of the quantitative survey for being unwilling to donate their breast milk. A 30-year-old woman said, ‘that it is not hygienic and that any disease that runs in the family could affect the child who takes such milk’. A 32-year-old woman gave religious reasons for being unwilling to donate her breast milk or accept her baby to be fed with DHM. She said that it is not allowed in the Islamic religion. She said that the children who take milk from the same source must not marry each other. ‘The two families must know each other and inform the children. It is forbidden in Islam for the children to marry later on in life’ she retorted.

Willingness to accept DHM

When asked if they will allow their baby to be fed with donated human milk (DHM) if the need arises, 677 (84.8%) declined while only 121 (15.2%) of the participants said they may agree.

Only 201 (25.2%) of the study participants said that they may accept DHM if given more information.

Findings from the FGDs were not particularly different as most of the participants were not in support of feeding their baby with DHM.

Reasons for willingness/unwillingness to accept/use DHM for infant feeding

Sixty-seven (55.4%) of the respondents will be willing to use DHM to feed their infant because they know that breast milk is the best for every child, 17 (14.0%) will accept it because it improves the immunity of the child and prevents infections, while 13 (10.7%) will accept it if the doctor advises them to use it. A sizeable number of participants 438 (64.7%) in the quantitative survey did not like the idea, 67 (9.9%) prefer to use of breastmilk substitute, 91 (13.4%) believed the collection and use of human milk is unhygienic and can transmit infections while 28 (4.1%) feared genetic diseases transmission. Table 4 shows the reasons for willingness/Unwillingness to accept/use DHM.

Table 4.

Reasons for willingness/unwillingness to accept/use DHM.

Reasons	Frequency	Percentage (%)
Willingness to accept DHM (N = 121)
Breastmilk is the best for every child	67	55.4
Infant formula is expensive	9	7.4
Doctor’s advice	13	10.7
Improves Immunity & prevents Infection	17	14.0
Breastmilk protects against allergy	7	5.8
It is Cheap	8	6.6
Unwillingness to use DHM for Infant Feeding (N = 677)
I don’t like the idea	438	64.7
I prefer infant formula	67	9.9
It is unhygienic with an increased risk of infection transmission	91	13.4
There can be the transmission of genetic diseases to my child	28	4.1
My spouse/family will not agree	21	3.1
Traditionally and culturally unacceptable	25	3.7
Others	7	1.0

In one of the FGD sessions, there was a 28-year-old mother who also said that she does not mind giving her baby DHM as long as it was recommended by the Doctor. She said that the doctor knows that it is good for my baby, then I have to follow the advice.

The reasons given by the participants of the FGDs were not different from the quantitative survey findings. Most of them were afraid of the transmission of genetic diseases and infections. Three hundred and fifty-eight respondents (62.9%) prefer their relatives to donate milk for their baby if the need arises, 174 (30.6%) will opt for banked human milk while 37 (6.5%) will accept milk from their friends. Close to half (46%) of the participants were not interested in accepting DHM even if they were given more information about it, about a third (28.8%) claimed not to be interested in receiving more information about it while about a quarter (25.2%) claimed that they may likely accept DHM if they were given more information about it. Of the maternal socio-demographic characteristics relating to human milk acceptance and donation (Table 5); more women within the age group of 20–34 were willing to accept DHM while more women above the age of 35 years were more willing to donate compared with other age groups (p > 0.05). Higher proportion of women of the Islamic religion were willing to accept DHM (p < 0.05) and donate human milk (p > 0.05) when compared with their Christian counterparts. Also, higher proportion of married women were willing to accept DHM (p > 0.05) and donate human milk (p < 0.05) when compared with unmarried women. A significantly higher proportion of women who had secondary and post-secondary education were not willing to accept DHM (p < 0.05) and also not willing to donate human milk (p < 0.05).

Table 5.

Relationship between sociodemographic factors and respondents’ attitude towards human milk donation and use.

Variables	Acceptance for baby				Willingness to donate
Variables	Yes	No	Total	p-value	Yes	No	Total	p-value
Age group (years)
<20	2 (11.8)	15 (88.2)	17		3 (17.6)	14 (82.4)	17
20–34	93 (15.8)	494 (84.2)	587	0.66	170 (29.0)	417 (71.0)	587	0.438
≥35	26 (13.4)	168 (86.6)	194		40 (25.8)	144 (74.2)	194
Religion
Christianity	104 (14.3)	623 (85.7)	727	0.031	201 (27.6)	526 (72.4)	727	0.550
Islam	17 (23.9)	54 (76.1)	71		22 (31.0)	49 (69.0)	71
Ethnicity
Yoruba	107 (15.4)	585 (84.5)	692		201 (29.0)	491 (71.0)	692
Igbo	5 (11.4)	39 (88.6)	44	0.400	10 (22.7)	34 (77.3)	44	0.336
Hausa	0 (0.0)	7 (100.0)	7		1 (14.3)	6 (85.7)	7
Others	9 (16.4)	46 (83.6)	55		11 (20.0)	44 (80.0)	55
Marital status
Unmarried	4(8.2)	45 (91.8)	49	0.129	7 (14.3)	42 (85.7)	49	0.028
Married	117 (15.6)	632 (84.4)	749		216 (28.8)	533 (71.2	749
Maternal educational level
No formal/Incomplete Secondary	3 (5.1)	56 (94.9)	59		5 (8.5)	54 (91.5)	59
Completed Secondary	41 (17.2)	197 (82.8)	238	0.033	56 (23.5)	182 (76.5)	238	0.00
Post-secondary	77 (15.4)	424 (84.6)	501		162 (32.3)	339 (67.7)	501
Maternal occupation
Unemployed	8 (20.5)	31(79.5)	39		11 (28.2)	28 (71.8)	39
Unskilled	40 (14.0)	245 (86.0)	285	0.614	69 (24.2)	216 (75.8)	285
Semi-skilled	64 (16.0)	337 (84.0)	401		117 (29.2)	284 (70.8)	401	0.220
Skilled	9 (12.3)	64 (87.7)	73		26 (35.6)	47 (64.4)	73
Parity
Nulliparous	6 (15.8)	32 (84.2)	38	0.101	6 (15.8)	32 (84.2)	38	0.989
Primiparous	48 (19.6)	195 (80.4)	243		43 (17.7)	200 (82.3)	243
Multiparous	64 (13.2)	422 (86.8)	486		85 (17.5)	401 (82.5)	486
Grand multiparous	3 (9.7)	28 (90.3)	31		5 (16.1)	26 (83.9)	31

Among the obstetrics factors (Table 6), it was noted that more women who had breastfeeding counselling during antenatal care were willing to donate their breastmilk or accept DHM but the effect was not significant. However, many of the respondents were not willing to donate or accept DHM despite receiving counselling on breastfeeding during the antenatal period.

Table 6.

Relationship between obstetric factors and willingness to donate or accept DHM for infant feeding.

Variables	Acceptance for baby				Willingness to donate
Variables	Yes	No	Total	p-value	Yes	No	Total	p-value
ANC in last pregnancy
Yes	111 (15.4)	608 (84.6)	719	0.297	201 (28.0)	518 (72.0)	719	0.239
No	4 (9.8)	37 (90.2)	41		8 (19.5)	33 (80.5)	41
Place of ANC
None/Mission/TBA	7 (11.9)	52 (88.1)	59		12 (20.3)	47 (79.7)	59
Health centres	38 (16.5)	192 (83.5)	230	0.788	60 (26.1)	170 (73.9)	230	0.255
Private hospitals	20 (16.8)	99 (83.2)	119		40 (33.6)	79 (66.4)	119
State/Specialist Hospital	46 (14.8)	265 (85.2)	311		89 (28.6)	222 (71.4)	311
Breastfeeding counselling during ANC
Yes	103 (16.3)	528 (83.7)	631	0.079	182 (28.8)	449 (71.2)	631	0.156
No	8 (9.1)	80 (90.9)	88		19 (21.6)	69 (78.4)	88
Mode of delivery
SVD	92 (14.8)	529 (85.2)	621	0.607	158 (25.4)	463 (74.6)	621	0.007
Caesarean section	23 (16.5)	116 (83.5)	139		51 (36.7)	88 (63.3)	139
Postnatal care
Yes	47 (14.4)	280 (85.6)	327	0.612	85 (26.0)	242 (74.0)	327	0.419
No	68 (15.7)	365 (84.3)	433		124 (28.6)	309 (71.4)	433
Breastfeeding counselling at PNC
Yes	46 (14.7)	266 (85.3)	312	0.803	79 (25.3)	233 (74.7)	312	0.261
No	69 (15.4)	379 (84.6)	448		130 (29.0)	318 (71.0)	448
Exclusive Breastfeeding of the last baby
Yes	78 (13.9)	482 (86.1)	560	0.121	158 (28.2)	402 (71.8)	560	0.461
No	37 (18.5)	163 (81.5)	200		51 (25.5)	149 (74.5)	200

ANC: antenatal clinic; PNC: postnatal clinic; TBA: traditional birth attendant; SVD: spontaneous vaginal delivery.

More women who delivered via caesarean section 51 (36.7%) compared to those who had SVD (25.4%) were willing to donate their breastmilk or accept DHM. Overall, the majority of the respondents were not willing to donate or accept DHM irrespective of the mode of delivery. It is also important to note that post-natal care and breastfeeding counselling during postnatal care did not improve the respondents’ views or ideas about human milk donation. Though more than 70% of the respondents claimed to have practiced exclusive breastfeeding in their last pregnancy, this did not have any effect on their willingness to accept or donate human milk.

Discussion

The benefits of human milk have been widely reported and propagated. Despite this, MOM may not be available or sufficient in some special situations. Such conditions would include maternal unavailability from perinatal morbidities or illnesses such as HIV infection, medications or demise, multiple births. Such situations will warrant the use of alternatives to MOM and the closest is the DHM which is screened and pasteurized to ensure its safety and wholesomeness.¹⁷ This study conducted in the Southwestern part of Nigeria revealed poor knowledge about human milk banking (HMB), with only 21.6% of respondents having heard of it. This is comparable to the 25.8% reported in South-south Nigeria but lower than the 39% reported in south-east Nigeria.^12,18 The suboptimal knowledge is not likely related to maternal education as the majority of participants had post-secondary school education. The lack of HMB practice in Nigeria and neighbouring countries may contribute to the low awareness. The authors suggest that policy interventions are needed to promote and establish HMB in Nigeria.

The willingness to donate milk was slightly lower in this study than that reported in other Nigerian studies but comparable to a study in South-south Nigeria by Iloh et al.¹² In Ethiopia, a lower proportion of mothers were willing to donate, while in Southern Australia, all breastfeeding mothers were willing to donate.^7,19 Cultural differences and access to information about HMB could explain this difference. Less than 50% of participants in this study received information about HMB from healthcare workers, similar to what was reported in a study in Benin.¹⁸

Participants in the study expressed unwillingness to donate breastmilk due to concerns about transmission of diseases or infections and feeling that it was not the right thing to do. This is consistent with similar reports from other countries, such as Kenya.¹⁷ Lack of appropriate information about HMB and its processes may contribute to these concerns, indicating a need for public enlightenment on HMB.

The study found that despite receiving information about HMB from healthcare workers, most participants were not willing to donate or accept DHM, indicating the need for healthcare workers to acquire more education about HMB. The proportion of respondents who heard about HMB from electronic and print media is lower than what was reported in Turkey.²⁰ This finding highlights the potential of electronic media in increasing awareness and disseminating information about HMB.

It is also noteworthy that four out of every five participants in this study were unwilling to allow their babies to be fed with DHM, which agrees with the findings of Abhulimhen et al.¹⁸ in Benin. Many of the participants claimed they just didn’t like the idea while a few will reject the offer because they believe it is unhygienic and that it can increase the risk of infection transmission. In climes where HMB is practiced, facilities for bacteriological testing and treatment are available to ensure that banked milk is wholesome and rid of infection.²¹ About a 10th of this category of mothers prefers the use of breastmilk substitutes to DHM. Studies have reported the superiority of DHM compared with breastmilk substitutes in terms of better tolerability by preterm neonates, effectiveness in reducing the risks of late-onset sepsis, and significantly reducing the risks of NEC in newborns especially preterm babies^22–24 as well as significantly reducing the length of hospital stay for sick infants and saving on the cost of healthcare.^8,25 Very few hinged their reason on cultural beliefs while some mothers rejected the offer based on religious belief. While culture and religion have been reported to affect human lifestyle, it has also been reported to have a negative influence on health-related choices.²⁶ Most of the reasons given for the rejection of HMB are still evidence of inadequate and inappropriate information about HMB which can be corrected through enlightenment campaigns. These reasons are not different from what has been documented in previous studies.^2,7,17,18

Most of the study participants were counselled about breastfeeding during antenatal, outpatient clinic visits, and immunization visits; these counselling sessions did not improve the acceptance of this infant feeding option among our study participants. This may reflect the content of information given during such sessions. There may be a need to encourage healthcare workers to include information about HMB in their counselling sessions. Censored information, education, and counselling materials should be made available with reference to further access to information that the participant can read on their own.

Nigeria has not adopted this WHO-recommended method of alternative infant feeding. Hence the need for multiple stakeholders’ meetings to establish the use of DHM as an alternative infant feeding method. Previous studies conducted in other regions have also reported that various challenges, including cultural and religious beliefs, inadequate information, and poverty, hinder the success of HMB establishment. The involvement of opinion leaders in the community, religious leaders, traditional leaders, media practitioners, and healthcare workers is essential in tackling these challenges and ensuring that the interests of different groups are taken care of. However, this study found that about half of the participants were still unwilling to use DHM even with more information, highlighting the need for continued education and advocacy.

Concerning the choice of donor, of those willing to feed their children with DHM, most of them prefer to use milk from their relatives, this is different from the findings of Kimani-Murage et al.¹⁷ where most of the participants (63%) were only interested in accepting DHM from any healthy mother. Notably, in settings where HMB is practiced, pooled milk sources are usually in place, and donors are usually de-identified.

This study highlights the need for increased awareness of human milk banking (HMB) in Nigeria as a recommended alternative infant feeding option. Healthcare workers should provide adequate information, education, and counselling to mothers about the steps involved in HMB. Policymakers and stakeholders should collaborate with religious leaders to establish HMB in Nigeria and dispel myths and wrong information about the practice.

Footnotes

Acknowledgements

The authors acknowledge all the study participants, the research assistants and the resident doctors who assisted with the data collection.

Authors’ contributions

The study was conceived and designed by EOO and IOD. EOO, AOB, ATA, ABA, OAL, ABT. OAF and AEA assisted with data collection. EOO, IOD and OAF analysed the data. EOO wrote the initial draft. IOD, AOB, ABA, ATA, OAL, OAF, ABT, OBB, AEA and OOS critically reviewed the manuscript. All authors read and approved the final draft of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Olatunya Simeon Olatunya

Significance for public health

Are nursing mothers in the southwestern part of Nigeria open to donor human milk (DHM) as an alternative to mother’s own milk since previous studies in other regions of Nigeria revealed a low level of acceptability?

● This study showed that DHM from human milk bank is still not an acceptable alternative to the mother’s milk amongst nursing mothers and pregnant women in Ekiti State, Southwest Nigeria.

● There is a lack of awareness about this method of infant feeding which will affect the level of acceptance of this alternative feeding option.

● There is a need for public enlightenment campaigns about human milk banking in order to improve the knowledge of mothers and hence the acceptability of this method of infant feeding.

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Human milk banking acceptability among pregnant and nursing mothers in Southwest Nigeria

Abstract

Background:

Study Design and Methods:

Results:

Conclusions:

Keywords

Introduction

Methods

Inclusion criteria

Exclusion criteria

Sample size

Results

Awareness about HMB

Opinions and concerns about HMB

Willingness to donate breast milk

Reasons for willingness to donate breast milk

Reasons for being unwilling to donate breastmilk

Willingness to accept DHM

Reasons for willingness/unwillingness to accept/use DHM for infant feeding

Discussion

Footnotes

Acknowledgements

Authors’ contributions

Declaration of conflicting interests

Funding

ORCID iD

Significance for public health

References