Challenges in implementation of mother milk banks in Rajasthan: A situational analysis

Breastfeeding is an innate right of every newborn and a complete source of nutrition for newborns. The mother must introduce breastmilk to the infant at the earliest opportunity. A child must be exclusively breastfed till 6 months, after which supplementary food can be added [1]. Breastmilk is an astonishing emulsion that contains nutrients, enzymes, immune factors, and growth hormones for the adequate growth of a baby [2]. Together with this, the immune-protective and digestion factors make it supreme among all other feeding competitors. Omega-3 fatty acids are essential for brain development, and are supplied only in breastmilk [3]. For the baby, it has all the nutrients in proper proportion for optimal growth and development [3]. For the mother, it reduces the probabilities of cancer, delays subsequent pregnancy, promotes early expulsion of the placenta, and reduces post-pregnancy complications.[3] Above all, it ensures a strong mother-child bond [3].

Donated human milk (DHM) is the desirable alternative when a mother’s milk is not available; this was communicated as a joint statement by WHO - UNICEF through the Baby-Friendly Hospital Initiative in 1980 [4]. Donor human milk provides similar immune protection and may prove revolutionary in reducing infant morbidity and mortality. It becomes the responsibility of the government to achieve breastfeeding goals such as promotion of exclusive breastfeeding, reduction in the use of formula feed, establishing milk banks, and more.

A Mother Milk Bank (MMB) is a facility that allows the collection and distribution of human milk donated by lactating mothers other than the biological mother. The last few decades have seen the establishment of several milk banks as a nutritional source for sick and low-birth-weight infants, orphan and abandoned children, medical conditions where a mother cannot produce sufficient milk for the infant, and unfortunate maternal death.

Despite the worldwide decline in child mortality, the infant mortality rate in India continues to be over 30 per 1000 live births [3]. Malnutrition in children is more an interplay of female illiteracy, ignorance about the nutritional needs of infants and young children, and poor access to health care. Besides these factors, 27 million babies are born per annum in India, of which 3.5 million are preterm and 7.5 million are low birth weight [5]. These babies are vulnerable in terms of survival and cognitive development and typically have feeding problems due to their medical conditions.

In Asia, the first milk bank, “Sneha”, was established under the leadership of Dr. Armeda Fernandez at Sion hospital in Dharavi, Mumbai, in 1989; this is now a 30-year-old body nurturing the newer establishments through its experience [6]. There are more than 50 donor milk banks in India to date. In 2014, human milk banking guidelines were published which became the basis for the establishment of new MMB [7]. Later, standard operating protocol (SOP) for human milk collection, storing, and dispensing for babies admitted at health facilities was developed, and manuals were written by the Government of India (GOI) in 2017 [5]. DHM offers immense potential to curb the high rates of infant mortality, morbidity, and malnutrition [5]. Despite the established benefits of DHM, its growth in India is limited.

Rajasthan Government launched “Amrut-Kaksh” as a component of the National Nutrition Mission 2022, to communicate with rural communities to promote exclusive breastfeeding till 6 months [8]. The first mother milk bank, “Jeevan Dhara”, was inaugurated in 2015 in Udaipur by an NGO in the government setup. Also, “Divya Mother Milk Bank”, the first community milk bank, was established as a non-public setup in Udaipur [9]. Today, Rajasthan has around 19 milk banks, under the name Aanchal Mother Milk Banks (AMMB), which are the highest in number as compared to other states. More milk banks are in the pipeline [8].

The present study discovers the challenges within the operationality of the established Aanchal Mother Milk Bank in Rajasthan. It also captured the perception of beneficiaries and health care providers for the utilisation of donor milk. This, in turn, would offer evidence for the successful implementation of lactation management centers at public health facilities, and would benefit the most vulnerable part of the community, that is, infants, by reducing mortality rates.

This qualitative study was conducted to explore the challenges faced in the implementation of the AMMBs in Rajasthan. For study purposes, data was collected from the currently functional three oldest AAMBs, located at Tonk, Alwar, and Chittorgarh district of the Rajasthan.

Stakeholders related to the functioning of selected AMMBs are the medical officer, mother milk bank in-charge, staff nurse, technician, lactation counselor, and administrative officer. Lactating women visiting the selected mother milk banks were selected as participant mothers.

Criteria for Donors: A lactating woman who is in good health, feeds her baby satisfactorily, is willing to undergo blood testing, and has the enthusiasm to become a breastmilk donor. A donor is disqualified if she fails the checklist for becoming a donor, which includes viral blood markers, alcohol/tobacco use, undergoing any radiotherapy, mastitis, or any fungal infection in the breast area [7].

Criteria for Recipients: DHM is supplied on a priority basis for preterm and sick babies, mothers with postpartum illness, mothers with insufficient/absent lactation. If supplies of DHM are sufficient, they may be given when conditions such as the temporary interruption of breastfeeding, as when certain breast conditions (breast engorgement, cracked nipples) reduce the required feed of the infant. DHM is also made available when alternative feeding is required: for abandoned neonates, in case of maternal death, adopted neonates, a child unable to suck, child potential for multiple co-morbidities, or newborn weight loss [7].

A situational analysis was planned to explore the functioning of selected AMMBs after permission from concerned authorities. A face-to-face interview was conducted using the In-depth interview (IDI) guide for lactating mothers (n=30) and health care providers (n=25) to understand their knowledge, attitudes, and practices on DHM and MMB. The questionnaire was also directed towards eliciting information on sociodemographic details. Interviews were conducted in local languages – Hindi and Marwari – ensuring respect for local cultural and religious sensitivities. The participant was informed about the aim of the study and informed consent was obtained. Those who refused consent were excluded from the study (n=5). Privacy, confidentiality, and volunteerism of participants were ensured. Interviews lasted for 25–30 minutes. Audio-recording was done to collect data and field notes were made. After content analysis of interview data, transcripts were obtained. After comparing differences and similarities, codes were formed by two authors. The process of writing and rewriting themes continued until participants’ expressions were captured precisely. Data saturation was achieved till no new themes emerged. After discussion with experts, themes that best expressed participants' experiences were finalised. Verbatims of the lactating mothers are symbolised as M and the healthcare providers as H. Interviews were conducted by one researcher to ensure a high level of consistency [10].

The Root Cause Analysis framework was used to understand the various challenges. This is a comprehensive approach to discover the root causes of problems or challenges. A fishbone diagram (Ishikawa model) was used to summarise the underlying bottlenecks to find appropriate solutions [11].

It was insightful to assess the current practices and actual performance of AMMBs. A total of 30 lactating mothers and 25 health care providers were interviewed in 3 selected AMMBs. Most mothers belong to the age group 20–34 years and were unemployed. The study shows 66.6% have a residence in urban areas, and 40% were illiterate. Most of the participating health care providers were 25–36 years old and have a residence in urban areas (92%). Around 66.6% of mothers had heard about MMB through health care providers. The remaining 33.3% of mothers had heard from relatives who had used the service of AMMB. Few mothers (30%) fear donating milk due to less milk for their babies, but on counseling, they agreed. Few mothers (23.3%) were unwilling to utilise donated milk due to fear of infection.

The challenges observed in the functioning of the Aanchal mother milk banking practices are classified into major themes as system and community challenges (Fig 1). The system challenges have been further described using subthemes such as structure, financial support, operational process, technical procedure, quality maintenance, human resources, demand-supply ratio, knowledge, attitude, and practices about DHM and milk banking. The community challenges are categorised as lack of awareness and motivation, cultural myths, and taboos. The verbatim quotes of the participants are discussed in Supplementary file 1.

Figure 1

The Government of India is progressing to scale up the setup of the Comprehensive Lactation Management Centers (CLMC) model at the Tertiary level of public institutions with a high load of sick newborns with NICU facilities [7]. Our study provides an outline of the challenges of established mother milk banks, together with barriers and facilitators in milk bank practicing. Also, the study highlights the extent of knowledge and awareness among key stakeholders about DHM and its benefits. It also brings interesting concerns of mothers in donating or utilising milk.

The study offers insight into the present status of established AMMB in Rajasthan. Challenges such as shortage of funds, human resources, laboratory testing together with equipment maintenance, and risk of milk contamination, especially during thawing, must be addressed by ensuring adequate safety measures. Sometimes issues such as positive culture led to discarding a full batch of pooled milk. Our study emphasises the necessity to strengthen the quality and process of milk banking with technological innovation.

It was important to explore the mother’s perception of different feeding choices for the newborn. Most mothers believed that breastfeeding was superior to formula feeding. Mother Own Milk (MOM) is beneficial for child growth and also helps develop bonding. Formula feeds are costly, and moreover are likely to cause indigestion [5]. Mothers commented that the health education they received during pregnancy influenced their feeding choices. This indicates the requirement of counseling mothers during the pregnancy period and builds concepts on infant feeding based on scientific evidence for newborn development. Furthermore, family members and community leaders should also be targeted for Social Behavioral Communication Change (SBCC) interventions due to their cultural and religious influences.

In many developing countries, the use of donor human milk isn’t generally accepted [12]. In our study area, some mothers would hesitate to give donated human milk to their babies due to the risk of disease transmission; this is similar to findings in Ethiopia [13]. Maternal protective instinct decreases their willingness to utilise DHM, while the thought of sharing as an act of sisterhood gives them happiness and motivates them to donate milk. Most mothers knew the importance of breastfeeding to a child. But in conditions when the mothers have difficulty in expressing sufficient milk, the provision of DHM relieves them. Few mothers shared that donating milk is time-consuming, which acts as a barrier to their willingness to donate. Similarly, Mackenzie et al. in South Australia recorded that lactating women supported donating their expressed milk while mothers will use donated milk if safety concerns are given attention [14]. Very few mothers were unaware of milk banking. Acceptance of MMB would increase in a similar pattern as with blood donation services as mentioned by the author in one study [15].

In our study, the main reason for the unwillingness to donate breast milk and accept donated DHM for feeding was religious practices. Sociocultural values play a prominent role in influencing mother behavior. But counseling mothers on breastfeeding benefits during their pregnancy, and a further visit to NICU, help in developing faith in milk banking practices. In contrast, a study was conducted in Brazil where following NICU visits there was a 90% reduction in milk donation by mothers [16].

In Chittorgarh AMMB, the highest number of lactating women were registered for milk donation. This demonstrates better promotion activities, awareness, and willingness of mothers to breastfeed their children in this locale. Most of the donor mothers (70%) were in the age group of 20–32 years. The reason behind their motivation is the social value attached to breastfeeding, which is inculcated in them from a very young age.

In Tonk AMMB, the main barrier in counseling mothers was the cultural reservations considering milk banking as malpractice. This finding contradicts a review in Mumbai, where there was no role of specific communities in milk donation rates [15]. Also, most mothers undergo cesarean section with transfusion, which disqualifies them as per donor criteria, and they have reduced breastfeeding success [16].

In Alwar AMMB, the need for support from family members in the form of taking care of elder siblings, helping in household chores, and caring for the mother emerged as important findings.

Dissemination of information on milk donation within the community will help satisfy the milk requirement of babies within the government hospital along with babies who will be delivered at home or in private facilities. A study in the Metropolitan cities in India made similar suggestions: that the advantages and processes of MMBs should be shared in the community to generate awareness and acceptance for MMBs. Having an adequate number of lactation counselors, strengthening lactation support, and counseling by the service providers, especially nursing staff, will improve breastfeeding and milk expression for sufficient feeding of mothers’ own babies and donation [17].

Our study highlights the role of counseling in sustaining optimal feeding practices. Counseling is currently provided in groups; personalised and one-to-one counseling is going to be simpler. There is a need to increase the number of dedicated lactation counselors as per the load at facilities and strengthen the capacities of the staff through periodic training. Also, there should be a provision for displaying Information, Education, and Communication (IEC) material in local languages in health facilities, so it is well understood by mothers and families.

This study highlighted the role of facilitators in determining breastfeeding practices. In our study, the role of feedback from the recipient mother was also important in the successful establishment of a human milk bank. This is in contrast with the Hong Kong study, where discouragement from healthcare professionals was observed [18]. The government-supported milk banking network has successfully demonstrated its effectiveness as a part of the breastfeeding program. Keeping in mind the Indian perspective, where the frameworks about the development of human milk banks are still maturing, our study findings provide baseline information to address the barriers to the implementation of mother milk banks in India.