Abstract
Introduction
Breast milk is globally recognized as the optimal source of infant nutrition due to its immunological and neurodevelopmental benefits. In low-and middle-income countries like Bhutan, limited availability of donor milk and absence of milk banking infrastructure hinder neonatal nutrition. While breast milk sharing for feeding has been explored elsewhere, little is known about maternal and nursing perspectives of milk donation for research use within Bhutanese sociocultural context.
Objective
To explore breastfeeding mothers’ perceptions of breast milk sharing and donation for both nutritional and research purposes, emphasizing the facilitating role of nurses.
Methods
A qualitative exploratory design was used. Fifty-nine participants, 44 breastfeeding mothers and 15 neonatal intensive care unit nurses, from Jigme Dorji Wangchuck National Referral Hospital, Thimphu Bhutan, were recruited through purposive sampling. In-depth semistructured interviews were held between March and May 2022. Data was thematically analyzed following Braun and Clarke's six-phase framework using NVivo 12 software.
Results
Four themes emerged: (1) Breast milk sharing nutrition; breastfeeding mothers (- CHDM 13) expressed altruism but feared diseases transmission and cultural restriction; (2) Breast milk donation for research; breastfeeding mothers (NICUN 11) perceived potential societal benefits yet cited infrastructural gaps and religious hesitancy; (3) Nurses as facilitators on breast milk nutrition; neonatal nurses (NICUN 2 & 4) promoted breastfeeding and informal sharing despite lacking standard operating procedures (SOPs); and (4) Nurses’ role in research; nurse (- NICUN 4) viewed research as transformative but faced capacity and resource constraints.
Conclusions
Support for breast milk sharing in Bhutan is conditional, shaped by altruism, cultural norms, safety concerns, and system readiness. Strengthening nurse training, developing SOPs, and culturally sensitive community engagement are essential for promoting safe, ethical milk sharing and research participation.
Introduction
Breast milk is universally recognized as the optimal source of infant nutrition (gold standard) because of its unique composition of macronutrients, immune factors, hormones, and other bioactive substances that support growth, neurodevelopment, and protection against infections (Bagga et al., 2023; Sharma et al., 2020). In 2018, global reports indicated that about 40% of preterm infants did not receive adequate breast milk during the initial week of life (Israel-Ballard, 2018).
In many cases, mothers are unable to provide sufficient milk due to illness, separation (prematurity, maternal hospitalization), or death. In such situations, donated human breast milk is considered the next best alternative, especially for preterm or low-birth-weight infants. Human milk donation (also called donor human milk via milk banks, or peer-to-peer sharing in informal contexts) involves expressing milk from a lactating mother who voluntarily provides it, followed by appropriate screening, processing, storage, and distribution. This practice has been promoted by internationally as a safer alternative to infant formula when maternal milk is unavailable (World Health Organization, WHO, 2021).
Improved outcomes in neonates, such as reduced incidence of necrotizing enterocolitis (NEC), feeding intolerance, and shorter hospital stay are reported with use of donated breastmilk; Infants deprived of their mothers’ breastmilk, when fed on the donated breastmilk showed significant improvement (Ahmed et al., 2024; Tu et al., 2022). Given these benefits of donated/sharing breast milk, with an increase in evidence underscores its value of donated breast milk, contributing to the growth of global force for the establishment of human milk banks. Until now, over 600 human milk banks have been established across 60 countries, mostly located in Brazil, the United States, Europe, and Asia. This gradual expansion has also elevated ethical concerns about the equitable availability of donated breast milk for critically ill infants (Fang et al., 2021). Additionally, in low- and middle-income countries (LMIC) like Bhutan, the incidence of extrauterine growth retardation is higher compared to the United States and Japan, primarily due to the absence of human milk banks and the lack of established protocols for breast milk donation (Pradhan et al., 2019). The growth and acceptance of human milk banks can be understood through the lens of individual and collective beliefs, which highlights diverse influencing factors from the personal beliefs to policy-level frameworks, requiring cultural respectful practices, and raising awareness on risk, benefits, and barriers, and essential in shaping mothers’ willingness to share or donate breast milk (UNICEF & WHO, 2023).
Literature Review
Evidence from diverse contexts shows that many mothers view milk donation positively. For example, a study conducted in Nairobi, Kenya, among postpartum mothers showed a robust willingness to share/donate breast milk, often motivated by altruism and personal beliefs (Srenivas et al., 2020). Similarly, a scoping review by Mathias et al. (2023), comprising literature from Sweden, the USA, Turkey, India, Europe, Asia, and Oceania recognized common individual enabler factors such as robust personal desire for infants in-need, upholding individual values of safeguarding, acceptance, autonomy, and wider societal concerns (Mathias et al., 2023). Beyond personal beliefs, studies have shown that social support played an utmost important role in promoting breast milk donation. Support from family members (Mathias et al., 2023; Srenivas et al., 2020), encouragement from community leaders who perceived breast milk donation as a generous and meaningful deed (Mathias et al., 2023) and healthcare providers including nurses, midwives, doctors, nutritional professionals, and community health workers, have been recognized as main facilitators of milk donation (Chagwena et al., 2020; Mathias et al., 2023; Srenivas et al., 2020).
A study conducted among healthcare providers in Zimbabwe, most of the doctors (78%), nutrition professionals (68%), and midwives (62%) encourage breastfeeding mothers to utilize donated breast milk. Furthermore, they expressed a willingness to donate human breastmilk, and are significantly greater than nurses (39%). They also encourage to donate breast milk to human milk bank and show a receptive mindset with establishment of human milk bank (Chagwena et al., 2020).
Concurrently, significant concerns have been stated among mothers regarding breast milk donation, including fear of disease transmission, safety and hygiene concerns, mistrust of screening and processing procedures (Mahlatjie et al., 2022), inadequate milk supply concerns and difficulty in expressing milk (Mahlatjie et al., 2022; Mathias et al., 2023), and deficient knowledge on human milk donation and banking (Mahlatjie et al., 2022; Srenivas et al., 2020). Social barriers have also been identified, especially cultural and religious beliefs against breast milk donation (Mahlatjie et al., 2022; Mathias et al., 2023). These challenges have been found in LMICs such as Kenya, South Africa, Eastern Uganda, Turkey, and India (Mathias et al., 2023). In addition, numerous studies highlighted persistent misconceptions: Such as fears that infants might somehow acquire donor's genes or traits, that the practice might affect bonding, or milk sharing (outside formal banks) that could be risky (Candelaria et al., 2018; Mahlatjie et al., 2022; Wambach et al., 2019).
While there is considerable international literature on mothers’ perceptions toward donated breast milk, especially for nutritional uses in preterm infants, very little is known about perceptions of breast milk sharing beyond nutritional supplementation (for example, donation for research), or the attitudes of nurses in facilitating those broader uses. In Bhutan, to the author's knowledge, there is no formal milk bank infrastructure, limited data on human milk donation practices, and sparse literature on how breastfeeding mothers perceive sharing or donating their milk, particularly for research purposes (Pemo et al., 2019).
Moreover, in Bhutan, breastfeeding practices are deeply rooted by cultural, traditional, religious beliefs, and kinship lineage factors. Family members play pivotal roles in shaping infant feeding practices through kinship lineage, often acting as decision-makers and strengthening the continuity of beliefs and practices. Traditional practices such as offering butter or honey soon after birth, signifying success and cleanliness, giving a single drop of water before bathing the infant, symbolizes the cleansing and fortunate commencement, remain ubiquitous. However, these traditional practices often act as barriers to exclusive breastfeeding (Pemo et al., 2019). Furthermore, many mothers believe that their diet could affect the quality of breast milk resulting in the mothers limiting food consumption. This belief reflects cultural ideas of passing intelligence and physical abilities to the infants (Pemo et al., 2019). Although there is no centralized religious dogma encouraging human milk banking, and culturally acknowledged towards donating breast milk (Pemo et al., 2019; Yıldız et al., 2023). In lieu of donating breast milk is ingrained in kinship reciprocity and Buddhist values of compassion however, established human milk banks could face uncertainty because of concerns on purity, lineage, and karmic transmission (Pemo et al., 2019). Beliefs about purity, disease, and familial obligations may influence willingness to donate; likewise, nurses may have varying degrees of knowledge about donation and research, depending on training and institutional support. Understanding these perceptions is essential for informing policies, educational interventions, and potentially establishing mechanisms for milk donation or sharing (both for nutrition and research) in Bhutan (Kuenzang & Vaswani, 2024). Hence, this article explores breastfeeding mothers’ perceptions on breast milk sharing and donation for research, with attention to nutritional perspectives, and the facilitating role of nurses.
Materials and Methods
This study adopted a qualitative exploratory design (in-depth interview) employing reflexive thematic analysis according to Braun and Clarke (2019). This method was selected to address the scarcity of evidence in the Bhutanese context, to explore live experiences and social meanings of breastfeeding mothers and neonatal nurses that cannot be effectively captured through quantitative method. The values of a qualitative paradigm (Big Q) design stress researcher subjectivity, organic and recursive coding process, highlighting deep understanding and engagement with data. In particular iterations of thematic analysis, flexibility is essentially limited by paradigmatic and epistemological assumptions surrounding meaningful knowledge production (Braun & Clarke, 2019).
Study Setting
The study was conducted in the Community Health Department (CHD) and the Neonatal Intensive Care Unit (NICU) of Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Thimphu, Bhutan. JDWNRH is a 350-bed tertiary-level hospital offering a range of services, including pediatric and neonatal intensive care. The hospital serves as Bhutan's primary referral center, managing the majority of the country's preterm and high-risk neonates. The study targeted breastfeeding mothers whose infants were admitted to the NICU, visited the CHD for immunization, as well as NICU nurses directly involved in neonatal care. The inclusion criteria were breastfeeding mothers aged 20–40 years, mothers of preterm infants (less than 37 weeks of gestation) admitted to the NICU, and mothers of infants (less than 12 months old) visiting the CHD for immunization. Nurses currently working in the neonatal ward during data collection. Mothers experiencing acute illness, poor prognoses, or emotional distress during the visit, as well as nonparental attendants, were excluded.
Sampling Technique and Sample Size
This study utilized a purposive, maximum variation sampling technique (Braun & Clarke, 2021), to capture the broadest range of breastfeeding mothers’ perspectives and experiences from both NICU and CHD. The inclusion of NICU nurses delivered a professional lens, acting as potential facilitators of milk donation/sharing and enabling data triangulation. Additionally, they associate hospital policy and milk storage infrastructure, and encourage mothers who may be overwhelmed by clinical demands. In accordance with reflexive thematic analysis principles (Braun & Clarke, 2021), the sample size for CHD mothers was pragmatically determined by their reflections on breast milk donation and sharing practices during personal or health crises and is often influenced by families, cultural, traditional, and religious beliefs prevalent in Bhutanese context. Also, to explore the donation practices for research, considering that NICU mothers were less likely to open in research-related donation. Moreover, NICU mothers provide real-time, in-depth insights into breast milk donation within medical urgency milieu and maternal distress. Data analysis was incorporated through interview process with emerging in-depth guiding consequent interviews. Data saturation was reached after 29 interviews when no new codes were recognized, and confirmed with two additional interviews. For NICU mothers and nurses, the sample size was determined by the notion of information power. Enrollment continued until the data reached an interpretive depth adequate to construct a nuanced and multilayered account of the breast milk donation/sharing practices (Braun & Clarke, 2021), within Bhutanese context.
Data Collection
A semistructured interview guide (see supplemental file) was developed based on literature review and expert consultation (validators), covering two main domains; for breastfeeding mothers: Perceptions of donating or sharing breast milk for infants in need and for research use. For NICU nurses: Perceptions of their role as facilitators of breast milk donation and its potential use in research. Data were collected between March and May 2022 by the principal investigator (PI) (first author). In-depth interviews lasting 45–65 min on average were conducted in English or the Bhutanese language, depending on participant preference.
Five interviews (two nurses, three mothers) were conducted virtually due to COVID-19 restrictions. To facilitate participation, consent documents in English and Dzongkha were wired to NICU nurses via WhatsApp for printing and distributed to participants, with prior permission obtained by phone. Researchers reiterated study objectives, procedures, audio-visual recording, confidentiality safeguards, and voluntariness. Conducted virtual interviews following signed consent, with physical copies later collected once restrictions eased. For participants with limited literacy, face-to-face interviews were conducted. However, most participants preferred oral consent prior to participation, including consent for audio recording. Although written forms were provided, most mothers requested verbal explanations in the local language. To minimize burden and address power imbalances, data collectors verbally disclosed all study details, emphasizing privacy and voluntariness. Interviews were conducted at the NICU nurses’ station due to space constraints, with pauses or rescheduling as needed to reduce interruptions and reassure mothers reluctant to leave their infants. Reinforced confidentiality, with assurances that participation would not affect NICU care. Yet, few participants refused participation due to their child's critical ill condition at the time of approach. To respect cultural norms and relational autonomy, mothers were permitted to have a female companion or their spouse present during the interview if they preferred. The PI ensured a comfortable and nonjudgmental atmosphere throughout, allowing participants to express their views freely. Nurses were interviewed in their tea room or outside the hospital premises after duty hours.
Ethical Consideration
Ethics approval was obtained from the Research Ethics and Board of Health, Thimphu Bhutan (Ref. No. REBH/Approval/2021/106 dated 10th September 2021). Participants were informed of the study's purpose, voluntary nature, and their right to withdraw at any stage without consequence.
To safeguard confidentiality and privacy, participants’ names were replaced with coded identifiers (“CHDM 1, 2, 3…,” “NICUM 1, 2, 3…,” and “NICUN 1, 2, 3…”). All audio recordings and transcripts were stored securely under lock and key, accessible only to the authors. The recordings were destroyed after transcribing and anonymizing. Any questions causing emotional discomfort were skipped at the participants’ request.
Data Analysis and Rigor
Demographic variables were analyzed descriptively using proportions. The interviews were recorded prior permission from the study participant. Qualitative data were analyzed thematically following Braun and Clarke's (2021) six-phase framework (Braun & Clarke, 2021); PI conducted all interviews to maintain consistency and rapport. Familiarization with data, initially commenced by PI by getting immersed. Audio recordings were repeatedly reviewed, transcribed, and translated into English. The translated transcript was read and reread, and notes were taken. Clarificatory interviews were held when the response was unclear and the interview guide was modified iteratively based on emerging data to reflect the development in-depth data. Line-by-line open coding (inductive) was performed manually and electronically (NVivo 12), capturing relevant words, phrases, and patterns. A structured coding legend was applied to ensure analytic consistency and transparency, each interview excerpt was labeled with who expressed/spoke, the interview number, and whether it reflected feelings, beliefs or actions. This systematic labeling enhanced traceability from raw transcript to thematic synthesis, reinforcing confirmability and auditability. This was supported by reflexive journaling, permitting to record insights and potential bias from the outset (Ahmed et al., 2024). After initial coding, similar codes were grouped into preliminary categories. A collaborative idea with a doctoral-level qualitative researcher (Co-author) was discussed, which highlights researcher reflexivity and rigor rather than intercoder reliability (Braun & Clarke, 2019). The team reviewed and compared the codes and categories across transcript to ensure internal consistency. Creating most meaningful and nuanced interpretation of the Bhutanese context. Overarching and subthemes were finalized through reiterative team discussions. Potential bias was minimized through reflexivity, peer debriefing, and maintaining a neutral stance during data collection. Analytical disagreements were resolved through discussion among the research team until consensus was reached. After iterative coding and theme consolidation, a conceptual map (Figure 1) was developed using the relationship node function and refined manually for visual clarity. The final themes were substantiated with verbatim quotes and contextual interpretation. Themes were refined to ensure they provided a coherent story of breast milk donation towards nutrition and for research purposes by breastfeeding mothers and NICU nurses in Bhutan.
Conceptual framework illustrating core themes related to breast milk donation.
Results
The results presented study participants’ demographic characteristics (Table 1) and thematic analysis of data (Table 2).
Demographic Characteristics of Breastfeeding Mothers and NICU Nurses (N = 59).
SD = standard deviation; CHD = community health department; NICU = neonatal intensive care unit.
Summary of Themes and Subthemes from Thematic Analysis of Interviews with Breastfeeding Mothers and NICU Nurses.
CHDM = Community Health Department Mothers; NICU = Neonatal Intensive Care Unit; NICUM = NICU Mothers; NICUN = NICU Nurses.
Table 1 presents the demographic characteristics of the 44 breastfeeding mothers and 15 NICU nurses. The mean age of breastfeeding mothers was 30.1 years (SD = 4.6), with 40.9% having attained middle-secondary education. The nurses had a mean age of 32.2 years (SD = 5.9), and majority (86.7%) held a diploma qualification.
Breastfeeding mothers’ perceptions of donating breast milk for nutrition and research.
Table 2 displays the - themes that emerged, - as mentioned below -
Breast milk donation for nutrition: Mothers revealed the factors/conditions whether they kept an open mind towards donation or decided against it. This segment deliberates on two themes from the interview: Favorable (emerged 3 subthemes) and unfavorable (5 subthemes). Breast milk donation for research: Factors that influenced mothers to keep an open mind towards breast milk donation and the factors that influenced them from donating. The interview brought out two themes: Positive (emerged 1 subtheme) and negative factors (3 subthemes).
Donation for Nutrition
Favorable Conditions
Beneficial from Breast Milk Donation
Breastfeeding mothers stressed the benefits of breast milk as a main source of nutrition. They constantly regarded donated breast milk as superior to commercial formula, highlighting its optimum nutritional value, heightening palatability and digestibility, and its contribution to infant's health. Moreover, they perceived early discharge from the hospital, and positively expressed to share their milk: Donated breast milk provides benefits for mothers with low milk production, helps to soothe crying, gains weight, and contributes to early discharge from the hospital (CHDM 8). Donated breast milk satisfies baby's own hunger and promotes baby's health (NICUM 10).
Current Breastfeeding Practices
All mothers stated practicing exclusive breastfeeding. Complementary foods were introduced after their infants were aged 6 months. Nonetheless, NICU mothers were planning to introduce complementary feeding only after their infants had completed 6 months: I gave only breastmilk and did not give any other foods until my baby was six months old. Not even a drop of water during first six months (CHDM 14). After six months, I am planning to give a small amount of our regular well-cooked food and additional fruits (NICUM 5).
Motives for Sharing
Mothers expressed a willingness to share breast milk with infants in need, without expecting any gift or compensation. Many stated positive intentions to become milk donors and expressed enthusiasm, regret or discomfort for not donating, and perceived all infants as same as their own infant: I want to help mothers who struggle to produce enough milk. Since babies often cry from hunger, I feel motivated to share my milk with another baby, and I am thinking of becoming a breast milk donor (CHDM 23)
Unfavorable Conditions
The unfavorable factors that impacted their willingness to donate included fear of pathogen transmission, negative experience with breast milk donation, cultural practice, family pressure, and undecided: No experience.
Fear of Pathogen Transmission
Breastfeeding mothers perceived the circumstances as unfavorable and disagreed to share breast milk due to fear of infectious pathogen transmission through breast milk: There is a possibility of transmitting diseases through breast milk to the baby if the mother is HIV-positive or has an unknown disease (NICUM 11)
Negative Experience with Breast Milk Donation
Breastfeeding mothers expressed negative aspects of breastfeeding that affected their willingness to donate. Concerns included limited breast milk production during the first few days, lack of proper breastfeeding techniques, and breast pain while expressing milk. Some mothers introduced commercial formula or cow's milk, often leading to cessation of breastfeeding. Moreover, they stopped feeding because of breastfeeding-related issues, and the occurrence of a subsequent pregnancy: I had my first child, who was five months old, however, I stopped breastfeeding because of breast issues, and became pregnant again (CHDM 1) I faced difficulties producing breast milk, and lacked knowledge of breastfeeding techniques. As a consequence, I fed my baby with lactogen (CHDM 28).
Cultural Practices
Breastfeeding mothers expressed religious barriers to sharing breast milk, specifically regarding the providing of milk from a female infant's mother to male infant. They were also concerned about dietary choices, which may impact milk quality: From a Buddhist perspective, breast milk donation is restricted in a certain case, particularly, when sharing breast milk from their female child's mother to a male child (CHDM 22).
Family Pressure
Generally, during the birth, elders or experienced from the family often accompany and guide the process in accordance with traditional customs. Elders in the family play a vital role not only during the birth but also in shaping practices in early childcare and breastfeeding. Mother expressed the role of the infant's grandmother, who actively intervened to dissuading another infant from sharing breast milk reflecting prevalence of socio-cultural beliefs: A mother of a newborn requested my breast milk but religious beliefs and culture in Bhutan dissuaded in sharing. My own mother, who is superstitious, refused because I delivered a girl while the recipient's mother had a baby boy. Yet, I personally do not hold strong beliefs, many elders remain to uphold these beliefs firmly (CHDM 8).
Undecided-no Experience
A few mothers described never having shared breast milk and remained inexperienced in doing so: I have never donated breast milk (NICUM 2).
Donation for Research
Positive Factor
An anticipation beneficial from research findings was identified as a subtheme, which can offer was positively associated with their willingness to donate breast milk for research use.
Anticipated Benefits from the Research Findings
Mothers acknowledged the benefits from breast milk donation, remarking its potential value for future purposes: I would like to share my breast milk, as research would bring substantial benefit. If the findings prove valuable, there should be no problem (NICUM 11).
Negative Factors
Nonetheless, there were factors impacting the donation of breast milk for research, and negative factors were identified as a main theme and three subthemes as mentioned below (Table 2).
Beliefs
Some mothers perceived breast milk donation for research was insufficient, raised religious restrictions and highlighted reasons like not being born from the biological mother: From a Buddhist perspective, sharing breast milk for research is restricted (CHDM 22).
Infrastructure (Collection and Storage Process)
Concerns raised due to the lack of infrastructure storage facilities to facilitate milk donation for research. Concerns were painful milk expression and time-consuming: We do not have equipment such as electric breast pumps. Expressing milk manually is time-consuming and often painful (CHDM 18).
Undecided: First Time as a Research Participant
Some mothers participated in research for the first time and were clueless: This is my first time as research participation and no idea about it (CHDM 16).
Perception of neonatal intensive care unit (NICU) nurses as facilitators of breast milk donation for nutrition.
Enablers
Nurses play a vital facilitative role in breast milk donation for nutrition and research, providing guidance, assurance, and practical support that permits mothers feel confident and enthusiastic to contribute. Their existence as reliable healthcare providers were a significant enabler (main theme), linking cultural and logistical issues related to milk donation. Identified two subthemes mentioned below (Table 2).
Current Practice: Imparting Information on the Importance of Breastfeeding and its Technique
Nurses played a main role in encouraging breastfeeding, initiating it early and executing their support to situation-based requirement. They stressed breast milk as ideal nutrition, more effective and economical than formula, and emphasizing benefits including prevention of NEC, natural hygiene, and decreased hospital stay. Reinforced confidence and skill in infant care by demonstrating breastfeeding techniques and cup feeding: We initiate breastfeeding as soon as possible and feed the donated breast milk of similar gestational age (NICUN 2). We teach cup-feeding techniques, such as pouring the milk into a cup, and we teach breastfeeding techniques such as positioning and attachment (NICUN 4).
Obtaining Verbal Consent
Nurses facilitate consenting process and allowing to discuss with family and friends, and clarifying doubts before agreeing to donate: We obtained verbal consent from both donors and recipients’ mothers (NICUN 1).
Barriers
Nurses met barriers in facilitating breast milk donation, limiting their effectiveness as facilitators, emphasizing the requirement for supportive systems and culturally sensitive approaches. The barriers comprise of 5 subthemes as mentioned below (Table 2).
Difficulty Communicating
Nurses faced arduous in convincing mothers from remote villages and those who were illiterate about donating breast milk: Parents from remote villages lack information about sharing breast milk, which poses challenges in gaining their acceptance (NICUN 11).
Intrinsic Belief
A nurse believed that the breast milk production is not expected in the first 72 h and administered IV solution to the infant: During the first 72 h of an infant's life, breast milk production is not expected, so IV solutions are administered (NICUN 5).
Extrinsic Beliefs
Traditional beliefs affecting breastfeeding practices, with some mothers restricting sharing milk from female infant's mothers to male infants. Nurses described impermissible of discarding milk in unclean areas, seeming as detrimental to infants. Unwillingness and concerns to donate due to limited milk production and could hamper the infant's nutrition and health: Mothers from remote villages believed their baby might become sick from sharing breast milk and from discarding excess milk in unclean places (NICUN 11).
Breaching Privacy and Confidentiality
Nurses’ concerns about the risk of breaching privacy and confidentiality when exploring maternal history. We may be exploring mothers’ antenatal booklet and personal views (NICUN 5)
Underlying Structure
Nurses faced challenges because of a lack of milk storage facilities, preservation issues, lack of guidelines or standard operating procedures (SOPs), and arduous feeding schedules: We lack guidelines or SOP and rely our experience (NICUN 3). Feeding is scheduled every three hours, requesting parents to come together to feed their baby. Issues remain regarding feeding timing and safety. We also lack a test kit to check for milk contamination (NICUN 4).
Perception of NICU nurses as facilitators of breast milk donation for research:
One main theme was identified as enabler and two subthemes (Table 2).
Enabler
Nurses stressed breast milk donation as crucial for infant nutrition and for progressing research. They regarded donation as a chance to alter neonatal care through evidence-based practice.
Anticipated Research Transformation
Nurses expressed that donating breast milk for research could enhance clinical arena and provide valid information tailored to the Bhutanese context. Through research could generate robust evidence for policymakers: Conducting research could improve in clinical settings and encourage the establishment of human milk banks, finally benefiting Bhutanese (NICUN 4).
Necessity to Conduct Research
Some nurses reported the necessity of conducting research but acknowledged having limited research knowledge: No research has been conducted in Bhutan. Therefore, it is necessary to conduct (NICUN 14).
Barriers
Nurses reflects uncertainty and limited confidence as research participation, delayed their competent to act as facilitators, and restricting the advancement of evidence-based practices. Two subthemes identified as mentioned below (Table 2).
Research Hesitancy
Many nurse never encountered these beliefs and were clueless about research: No idea at all about research. I did not encounter (NICUN 10).
Limited Research Funding
Nurses recognized limited research funding as a barrier to commencing and sustaining breast milk donation research: Research has huge financial implications, such as expenditure of equipment (NICUN 2)
Discussion
The interrelated perceptions of mothers and nurses address how breast milk sharing and research donation in Bhutan are ingrained within sociocultural beliefs, ethical sensitivities, and institutional structures. Nurses emerged as main mediating agents, linking mother intents, social standards, and complete willingness for safety and ethical practices.
Perceptions of Breastfeeding Mothers on Donating Breast Milk for Nutrition
Findings from this study demonstrated that the mothers viewed milk donation through the lens of cultural and nutritional significance. They reflected that the ideal practice for breastfeeding and sharing milk is less accustomed. Alike, hesitancies have been described among mothers in Uganda, were cultural standards and ethical issues to milk donation. This indicates that sociocultural milieu plays a crucial role across various situations, swaying willingness for donation (Mampane & Wolvaardt, 2024).
Consistent with findings from Uganda and Turkey (Ahmed et al., 2024; Akpinar et al., 2022; Hosseinzadeh et al., 2023; Vesel et al., 2023), Bhutanese mothers revealed that the nutritional aspects of breast milk are superior than commercial feed, addressing its crucial role in infants’ health. Aligning with World Health Organization (WHO, 2021) recommendations, almost all mothers in this study, exclusively breastfed for the first six months, with CHD mothers introduced complementary feeding and continued beyond two years. While NICU mothers are planning to introduce complementary foods after six months. Also, outlining as a kindness act and empathy to another infants, without expecting any gifts/compensation. Similarly, studies from Kampala, India, Southeast China, and Turkey, where mothers articulated voluntariness to donate milk (Ahmed et al., 2024; Karacan et al., 2024; Rojjanasrirat et al., 2023; Tu et al., 2022; Vesel et al., 2023). This unique value reinforces both breastfeeding practices and openness towards donation across various backgrounds.
However, Bhutanese mothers, similarly to those in Uganda and South Africa, stated unwillingness to share breast milk due to fears of pathogen transmission, (Magowan et al., 2020; Mampane & Wolvaardt, 2024). In LMICs, commercial formula is often unaffordable, as a result relying on cow's milk when mothers milk is insufficient production (Magowan et al., 2020). Similar barriers to donation were found in Nepal, India, Malawi, Tanzania, and Uganda, where mothers had insufficient milk supply, breast engorgement, inverted nipples, and soreness, thus replacing cow's milk, water, or glucose (Magowan et al., 2020; Vesel et al., 2023). In the present study, mothers had similar perspectives. African-American mothers demonstrated low acceptability of donated milk, often associated with issues about family dissuading and cultural standards (Ahmed et al., 2024; Akpinar et al., 2022; Ellsworth et al., 2021; Jahan et al., 2022). Similarly, in the present study it has been reflected that mothers expressed restrictions of milk sharing to cross-gender, acknowledging Buddhist beliefs, disallowing sharing of milk from mothers of female infant to male infant. Whereas, this perception viewed wider cultural concepts of male superiority, in Buddhist perspectives addresses equality among all sentient beings, and have not corroborated such boundaries. These results emphasize how cultural explanations, rather than doctrinal status, can generate barriers and may risk strengthening gender discrimination. Concerns about mothers’ diet and viewed influencing factor on milk quality by Bhutanese mothers in this study, similar with previous findings (Pemo et al., 2019). Infant grandmothers’ role was considered as a robust influencing factor on milk-sharing practices. In Bhutan, just-delivered women often relied on infant's grandmother to make decisions that are culturally acceptable, while in India, grandmothers have been demonstrated to discourage milk sharing because of fears of insufficiency (Mondkar et al., 2018).
Perceptions of Breastfeeding Mothers on Donating Breast Milk for Research
In this study, mothers mentioned diverse perceptions however limited understanding of donating milk for research. Minimal or without exposure on breast milk donation, have been revealed in various situations, even mothers from Michigan, faced similar experience (Ellsworth et al., 2021). Moreover, Bangladeshi mothers never heard of donated breast milk until they learned during research participation (Jahan et al., 2022). In this study, a similar situation was exposed by mothers to such a situation for the first time. Inexperienced mothers might face difficulties to intervene the acceptability of donation. However, a few mothers expressed of enhancing knowledge and generating meaningful value to Bhutanese society.
Cultural and religious beliefs generated as major concerns impacting mother's voluntariness to donate breast milk for research. The reasons were that the infants not born from biological mother, and perceived a prioritization of their own infant's needs over those of others, developing reluctant to donate.
Perception of a NICU Nurse as a Facilitator on Donating Breast Milk for Nutrition
In the present study, nurses played a vital role in initiating breast milk donation in the NICU, performed case-by-case basis and supporting mothers experiencing lactational complications. Donated breast milk of similar gestational age was encouraged, which have similar components and benefits. This result aligns with studies from India, Malawi, and Tanzania, where healthcare providers encouraged mothers through information on breast milk benefits and demonstrated techniques such as positioning, attachment, spoon feeding, and cup feeding (Tende et al., 2023; Vesel et al., 2023). Cup feeding, in specific, has been recommended in LMIC as an alternative feeding method because of its accessibility and ease of cleaning (Bala et al., 2024). Similarly, in the present study, nurses actively encouraged mothers. Studies from South Africa, where informed consent was highlights as vital for addressing moral concerns in the donation process (Mampane & Wolvaardt, 2024). Similarly, highlighted in this study.
However, in the present study, nurses faced barriers in approaching breastfeeding mothers from remote villages and illiterate, and they stated unawareness, reluctant towards milk donation, showing disbelief or shock. Similarly, a study from India corroborated such a finding where the authors deduced that denial of sharing breast milk could come from illiterate families (Mondkar et al., 2018). Also, a nurse believed that early breast milk as inadequate and resolving to IV glucose administration. While intended to maintain hydration, such practices risk pathogen infection and loss of colostrum. Comparable challenges have been described in Eastern Uganda, healthcare professionals fed infants with water and glucose due to insufficient breast milk (Magowan et al., 2020). Conversely, initiatives such as human milk banking in Ghana, the healthcare providers explain the storage of expressed breast milk for use to feed needy infants (Tende et al., 2023). However, nurses revealed confusion about proper storage of donated breast milk, often keeping it at room temperature for four hours. Apprehensions were arising among nurses, due to warmer units than other units, and likelihood of increasing the risk of spoilage. Also, lacks safety measures or test kits to check for contamination. Conversely, established human milk bank procedures necessitate efficient screening, collection, storage at −20 °C, pasteurization, and controlled distribution to ensure safety and quality (Karacan et al., 2024).
Perception of NICU Nurse as a Facilitator on Donating Breast Milk for Research Purposes
Findings from the interview, nurses perceived on donating breast milk for research intersect with each other, because of difficulties in determining the cause and effect on donation. However, research findings could anticipate transformation therefore, is necessary to conduct research, potential to quality of care. Nevertheless, in LMIC, nurses had limited exposure, minimal representation and lacks research knowledge (Amundsen et al., 2024). Similar, findings corroborated in this study.
Cross-Cutting Interpretation and Significance for Bhutan and Other LMICs
The code readings show that six interdependent factors systematically shape the acceptability and practice of milk sharing in this setting: (1) Perceived benefit (benefit-altruism), (2) pathogen and safety fears (fear-pathogen), (3) cultural/religious scripts (cultural-restriction), (4) family/elder gatekeeping (family-pressure), (5) health system infrastructure (infrastructure-gap), and (6) provider capacity and attitudes (nurse-knowledge/consent-verbal). Any single intervention that targets one node (awareness campaigns emphasizing milk's superiority) without addressing the others (providing cold-chain guarantees or engaging elders) will have limited impact. This multinode dependency is a common pattern across LMICs but manifests locally, the Buddhist gendered belief in Bhutan is a contextual exemplar that demonstrates the need for culturally specific strategies. For Bhutan specifically, the findings imply that policy actions should prioritize (a) establishing minimum technical standards for collection, screening, storage, and pasteurization (or referral pathways to regional milk-banking facilities), (b) investing in nurse training on counseling, consent, and research literacy, (c) designing culturally sensitive community engagement that includes elders and religious leaders, and (d) piloting small, transparent research projects with explicit data governance and benefit-sharing statements. Regional LMIC lessons, such as phased implementation of milk banks, task-shifting to trained nurses, and use of pasteurization to allay infectious concerns, are directly applicable but must be adapted to Bhutan's cultural matrix.
Implications for Nursing Practice
Consent practices require particular attention. The dominance of verbal-consent reflects pragmatic realities but may be insufficient where donations feed research. For ethical robustness, nurse researchers and nurses should use layered consent models: Initial verbal engagement at bedside, followed by written informed consent for research uses, and community-level consultations for culturally sensitive practices. Data governance must ensure anonymity and clarify who accesses recordings and data, respondents already voiced concern about potential privacy breaches. Institutionally, SOPs should be developed collaboratively (nurses, obstetricians, neonatologists, ethicists, community representatives). SOPs should cover screening criteria, cold chain standards (even for interim pilots), pasteurization options, storage durations, and contamination testing. Funding constraints are real, leveraging governmental, donor, or academic partnerships for pilot infrastructure will be necessary.
Strengths and Limitations
The study's strengths include purposive sampling across mothers visiting CHD and NICU nurses, rich interview data allowing code-based thematic analysis, and attention to trustworthiness (triangulation, translation checks). Limitations include single-site data (JDWNRH), potential social desirability bias (hospital-based interviews in semiprivate spaces and dependence on verbal consent), translation of informed consent by nonspecialist researchers and uneven/lack prior exposure to research among participants, which may have influenced responses. Transferability is plausible to other Bhutanese tertiary centers and to similar LMIC NICU settings, but cultural specifics (the Buddhist gender belief as applied to milk sharing) must be carefully considered before generalizing.
Conclusion
The study reveals conditional support for breast milk sharing in Bhutan: Altruism coexists with safety fears, cultural constraints, infrastructural gaps, and provider-level limits in research literacy. To translate conditional willingness into safe, equitable practice, findings indicate the need to pursue an integrated strategy: (1) Community-engaged education that includes elders and religious leaders; (2) nurse capacity-building on counseling, consent, and research methods; (3) development of SOPs and low-cost pilot infrastructure for safe collection and storage; and (4) ethically robust, transparent consent and data governance for any research use. Also, results indicate the offer an operational blueprint for other LMICs facing the same complex interplay of culture, safety, and scarce resources. Future research should explore how community education and nurse-led facilitation can reinforce trust and readiness for sharing of breast milk practices for nutritional and research purposes.
Supplemental Material
sj-docx-1-son-10.1177_23779608261439003 - Supplemental material for Breastfeeding Mothers’ and Nurses’ Perceptions of Breast Milk Sharing and Donation for Research in Bhutan: A Qualitative Study
Supplemental material, sj-docx-1-son-10.1177_23779608261439003 for Breastfeeding Mothers’ and Nurses’ Perceptions of Breast Milk Sharing and Donation for Research in Bhutan: A Qualitative Study by Kuenzang and Vina Vaswani in SAGE Open Nursing
Footnotes
Acknowledgments
The authors would like to acknowledge the National Institute of Health (NIH Grant No. IR25TW010305) Fogarty International Centre (YU-FIC) Masters in Research Ethics of which the Principle Investigator (PI) was a student when he carried out this research, and to Yenepoya (Deemed to be) University (YU-FIC), Mangalore, India for the support. Faculty of Nursing and Public Health (FNPH), Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB) - Thimphu Bhutan for logistic support. Staff of the Community Health Department (CHD) and Neonatal Intensive Care Unit (NICU) of Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) Thimphu, Bhutan, for providing permission to conduct the study. Mr. Ugyen Dorji, Ms. Jigme Zangmo, Ms. Kezang Wangmo and Ms. Sarala Pradhan, NICU nurses, JDWNRH, Thimphu Bhutan providing technical help. Ifeanyichukwu Akuma, PhD Research Ethics Scholar (Bioethics), Yenepoya (Deemed to be University), Mangalore, India for proof-reading and editing the language.
Ethical Approval
The research proposal underwent as mentioned below:
Scientific review by the Scientific Review Board (SRB) of Yenepoya (deemed to be University), Mangalore, Karnataka, India and approved on 07 July 2021. Administrative clearance was obtained from Ministry of Health, Bhutan (Ref. No.: PPD/admin.CI/ (9)/2020–21/120 on dated 16 July 2021). Ethical clearance from Research Ethics and Board of Health (REBH), Bhutan (Ref. No. REBH/Approval/2021/106 dated 10th September 2021). For site visit approval, obtained from the Head, Medical Education and Research Unit (MERU) of JDWNRH, Thimphu, Bhutan (Ref. No.: JDWNRH/MERU/01/2020–2021/6075 on dated 4 January 2022).
Informed Consent
Informed consent was taken before enrolling the participant in the study. Privacy, confidentiality, and anonymization of the participants were maintained throughout the study and was guaranteed.
Author Contributions
| Author | Name | Nature of Work | Signature |
|---|---|---|---|
| First Author | Kuenzang | Conception and design of this work, the analysis and interpretation of the data, as well as the writing of the manuscript | |
| Second Author | Vina Vaswani | Conception and design of this work, the analysis and interpretation of the data, as well as the writing of the manuscript |
We hereby declare that these are the only author(s). We will be responsible for any claim to the authorship beside listed above and SAGE Open Nursing will not be liable for such claims. We hereby agreed Mr. Kuenzang as corresponding author for this article. We give the rights to the corresponding author to make necessary changes as per the request of the journal, do the rest of the correspondence and he/she will act as the guarantor for the manuscript on our behalf.
All persons who have made substantial contributions to the work reported in the manuscript, but who are not contributors, are named in the Acknowledgment and have given me/us their written permission to be named. If we do not include an Acknowledgment that means we have not received substantial contributions from noncontributors and no contributor has been omitted.
K contributed to the design and interview with participants, analysis, interpretation, and drafting of the research manuscript. VV contributed to the inception, design, data analysis, interpretation, and editing of the manuscript for publication.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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References
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