Socio-demographic and maternal characteristics of the participants
The study was conducted from October 2018 to March 2019, we studied 410 postnatal mothers. Their median age was 29 years (IQR: 26-32), of these; 68.8% their age ranged between 25-34 years and 15.1% were 35 years or older. Majority (62.4% ) of the respondents were university graduates, 75.6% of the women were employed and 86.6% of them had attended at least four ANC visits. During their previous pregnancy, 54.6% of the respondents had attended only one PNC visit and the remaining had attended two or more PNC visits. (Table 1)
Acceptance to donate human breast milk
Of the 410 postnatal mothers interviewed, 77.6% (95% CI:73.5%-81.6%) were willing to donate breast milk, the most common reason to donate was if they have excess breast milk (66%).While 63% were willing to donate to help infant in need and 55% to support another mother those lack breast milk(Figure.1). On preference to donate breast milk, 58.1% of the respondents preferred donation to a relative, while on receiving donated breast milk, 94.6% of the respondents did not restrict to a relative. (Table. 2)
Reasons for accepting to donate breast milk
The commonest reasons for accepting to donate among postnatal mothers were having excess breast milk followed by helping infants in need and support mothers who lacked breast milk (Figure 1).While fear of disease transmission, anxiety around safety, genetic mixing, were the major reasons for not accepting to use donated breast milk, others preferred not to donate, non-supportive environments, cultural and religious issues (Table 2).
Acceptance to use donated human breast milk
When asked about the acceptance to use donated breast milk, of the 410 mothers interviewed 69.4% were willing to use and 31.5% were not willing to use donated breast milk. Among those who were willing to use donated breast milk 65.0% said it was because breast milk is the best food for infants, followed by breast milk is better for growth by 62.0%, and 22.0% of them was because breast milk prevents diseases. (Figure 2 ) Of the 129 (31.5%) mothers who were not willing to use donated breast milk, the most common reason to decline was fear for disease transmission 61.2% , a perception that donated milk is unhygienic (36.4%) and it was not accepted culturally (3.1%) (Table 2).
Participant’s awareness of human breast milk donation
On the awareness about the wet-nursing, 79.3% of the respondents had ever heard about wet-nursing and 50.2% of the respondents were aware of breast milk banking. 87.1% of mothers in the study had never breastfed another person’s child. 89.0% agreed that collecting and storing breast milk was useful. 68.3% of the respondents had ever visited under 5 OPD ward.
Factors associated with acceptance to donate human breast milk at St. Francis hospital Nsambya
At bivariate analysis acceptance to donate breast milk was affected by women's level of education. Women who were graduates had an OR of 1.94(95% CI 1.22 -3.11) times most likely to accept breast milk donation compared to non-graduates (p-value of 0.006). Acceptance to donate human breast milk was also affected by the level of education of women’s husbands, women who had graduate husbands being 1.8(95%CI: 1.09-3.00) times more likely to accept to donate breast milk (p-value of 0.023). Women who had heard about wet-nursing were 2(95%CI: 1.18-3.40) times more likely to accept breast milk donation compared to those who had not heard about wet-nursing (p-value of 0.010). Whereas women who believed that collecting and storing breast milk was useful were 6.28(95%CI: 3.15-12.52) times more likely to accept breast milk donation (p value <0.001) (Table 3).
At multivariate analysis having ever visited the under-five OPD 21.29 (2.30 - 196.9) p=0.007, heard about wet-nursing 2.33 (1.10 - 4.96), p=0.028 and being one who perceived collecting and storing breast milk useful 7.51 (3.01 - 18.68), p<0.001, were independently associated with accepting to donate breast milk (Table 4).
Most postnatal mothers in the qualitative component of the study were aged 25-34 years, more than a half of the mothers had attained tertiary education and almost all of them were employed see (Table 5).
Summary of quantitative results
The qualitative data explored reasons for acceptance to donate breast milk. And the results are presented using a Theoretical Framework of Acceptability of health interventions  and ends with recommendations from participants.(Table 6).
ENABLERS OF BREAST MILK DONATION
Breast milk best food/no substitutes
It was agreed among the FGD participants and KIIs that there was no substitute for breast milk for a new born baby whether preterm or full term. They noted that mothers who didn’t breast feed their babies were denying them the best quality food and that it would interfere with the proper development of their children. As one of the mothers stated
“Breast milk is well balanced with all nutrients whatever the mother eats the baby will get it through breast feeding.”(R1/FGD2, 31 years old, a mother of 3 children).
While another mother described breast milk as irreplaceable:
“However expensive the formula can be it is not a replacement to breast milk. Breast milk is very important to baby”.(R6/FGD1, a 25 years old who is first time mother).
A health professional also disagreed with the idea of mothers introducing formula milk to their new born babies as this could harm their babies. She considered formula milk as a risk to new-borns especially preterm babies as it may expose them to health complications
“…Nothing else other than breast milk their intestines can’t digest what you are giving them. So they will swell the tummies once you give them formulas.” (KII1 NICU nurse, a mother and frequent breast milk donor at st. Francis Hospital Nsambya).
Self-relief from pain or congestion
Some participants also considered breast milk donation as a way of reducing congestion of breast milk. They looked at it as a relief for the mother who is experiencing painful breasts due to milk engorgement.
“I can donate if I have enough to avoid the pain and swelling of the chest” (R5/FGD2, 25years old mother of 3 children).
“Most people have much milk like me I have excess and wet my blouses … so I will donate”(R3/FGD2, 25 year old first time mother).
While some mothers looked at it as a way of regulating breast milk flow to avoid chocking for their own babies especially for the mothers who have a lot of breast milk
“You would be breast feeding your baby and then you see the milk choking him/her that shows you that you have excess so to reduce it is better option when you donate to needy preterm”. (R1/FGD2, a 31 year old mother of 3 children).
Will rather donate breast milk than flash it out
Most of the participant’s demonstrated a confidence that they could donate if they have excess, especially due to the fact that the pre-terms are not likely to survive without breast milk. They considered breast milk donation as an act of kindness and a sacrifice to save a life.
“Really when I have excess and there is another mother who doesn’t have I would rather donate it to them than to flash it out. And some can’t even afford to buy the formula so there is need to really donate this milk to the needy mothers and pre-terms”(R5/FGD4, a 30 years old mother of 3 children).
Some participants attributed the willingness to donate breast milk to having a humane and motherly spirit and understanding that anyone can be in need anytime
“If you have a motherly spirit you will donate because these things are like this today with another person tomorrow it will be you crying and looking for a donor to bless your child. So it is good to donate and I think majority women will be willing to donate” (R6/FGD4, 28 years old mother of 3 children).
Seeing children grow on another woman’s milk (wet-nursing)
Most women who had seen babies wet nursed grow well or had heard about wet-nursing were willing to donate breast milk as one of the participants explained:
“I had my friend and her sister went abroad for greener pastures, she left a baby at 2 months and her sister used to breast feed two babies and they grew as if they were twins and they are 3 years…Wet nursing should be stopped completely and we resort to breast milk donation because the mother will have been tested very well at the hospital by the doctors.” (R2/FGD3, 28 years old first time mother).
Emerging from the above narrative is the appreciation that breast milk donation can help to overcome the limitations of wet nursing mainly the spread of infections and diseases to the baby.
“I think wet nursing is not good the world has changed and many ladies are sick with HIV and other diseases. It is not good it is better to donate because it is safe they test the donors and breast milk is kept safely.”(R4/FGD1, 23year old, first time mother).
Positive experience with donated breast milk
A few of the mothers had used donated breast milk and described how breast milk donation worked for babies, as one of them narrated.
“I have gone through a lot myself as a mother of a preterm when they told me to express milk but I totally had nothing until a nursing sister helped me. So I will be willing to help another mother I have learnt the hard way…I later saw my baby responding so well and looking better every other day until I got my own breast milk. So I can be willing to donate having learnt that helping is good and nothing bad another person’s breast milk can do to your baby once tested. (R4/FGD3, a 28-year-old first time mother).
While other participants believe that children grow healthy and develop immunity through breast milk as a mother explained:
“Children grow healthy, children gain resistance to diseases when they breast feed there is good immunity for the breast fed baby”. (R1/FGD3, 34 years old mother).
Another mother also related children’s education performance to breast milk where she said:
“I think the babies should breast feed because the human milk is good and they tell us that we should breast feed our babies well. I have 4 kids they are looking so healthy because of breast feeding and are brilliant in class”. (R8/FGD3, 33 year old mother of 4 children).
Breast milk saves lives, especially of premature
A great number of respondents considered breast milk donation as an act of saving the lives of the pre-matures. They all agreed that the greatest motivation for them to donate breast milk was because they knew that they were saving a life as these preterm babies could only survive on breast milk as a 26-year-old first time mother said:
“…So you need to be determined to do it [breast milk donation] and save a life.”
A staff and a mother also described the importance of breast milk and by seeing the vulnerable babies you will need to do good saying:
“But after learning about the superiority of breast milk over the formula then you get a heart to help someone who lacks, to save a life”.(KII2, a doctor at st. Francis Hospital Nsambya and a mother who ever donated).
Another health care professional stated that by breastmilk donation pre-terms can survive and they cannot tolerate formula.
“I am a mother so seeing someone’s babies die and also a healthy worker taking care of those babies I knew what could help those babies to survive. I knew what they could feed on and survive once such preterm babies are put on formula milk they will die”.(KII1 NICU nurse , a mother and frequent breast milk donor at st. Francis Hospital Nsambya).
Barriers to breast milk donation
The most common barriers to accept breast milk donation among participants were fear of: not having time, breast milk may not be enough for own baby, loss of body image, fear to test for HIV and know ones HIV status, and negative social cultural beliefs.
Mother may not have time to donate
Participants agreed that though most of them would be willing to donate, they were afraid that they may not have the time to come to the hospital to do it because of competing responsibilities. Others wondered if there would be mechanisms for collecting donated breast milk from home to relieve the donors the time of moving to the hospital.
“Some will be willing to donate but time. Some mothers are too busy to come to hospital to donate”.(R6/FGD2, a 25 years old of 3 children).
Some participants who are working suggested that it would be time saving if the milk could be collected from their places of work
“To add on that we working mothers we have no time you tend to forget your baby”.(R4/FGD1, 23 year old first time mother).
Fear the milk may not be enough for own baby
Some of the participants were afraid of not having enough breast milk for their own babies if they decided to donate. They looked at this as depriving their own babies at the expense of those who needed the milk as one mother noted.
“You might donate and then you end up lacking enough for your baby. There was a time I wanted to donate for a lady in ICU and before a short while something came up and stressed me and pressure short up and my breast milk disappeared for a whole day and a half …So for me I have that worry as you can donate but fail to produce enough for your baby”(R3/FGD1, a 33 year old mother with 3 children).
May lead distorted body image /breast sagging
The worry of women losing their body image as a result of donating breast milk was mentioned in all the four group discussions. The participants feared that pressing or pumping their breasts to produce milk would cause their breasts to sag and their bodies to lose shape yet this was a big concern to most women.
“Some people will wonder how they can breast feed their babies as well donate, will they fear to lose weight and be bum less and breasts grow floppy. So it might not work well.”(R2/FGD2 a 19 years old first time mother).
Other participants further noted that sagging breasts was not only a concern for the women but for their husbands as well as most men prefer to have women with firm breasts.
“Our spouses also don’t like floppy boobs (breasts) they keep looking for young shooting boobs. That is why women breast feed for a short while and then put them on the formula due to the demands of men.”(R7/FGD1,23 year old a mother of 2 children).
Some study participants argued that having a breast milk bank will be a means for women to escape breast feeding and opt to buy milk just to keep their breasts firm
“…While other say women will totally stop breast feeding their children totally in the guise that there is free breast milk in the breast milk bank, they can buy or follow all procedures to get it. That they would rather keep their boobs looking good and nice than breast feeding babies and they look old.”(R2/FGD2, 19 years old first time mother).
Implied in the above narrative is potential for likely misuse of donated breast milk and requires strict guidelines to attain the intended goal.
Fear to test for HIV and know ones sero-status/fear to transmit infections
One of the greatest fears that all the participants mentioned was the fear for testing or being tested for HIV before breast milk donation. This was a concern that potential donors would be afraid of being tested for HIV since it is a requirement for one to donate
“Most young mothers don’t like to test and know their sero-statuses. Instead they worry much and say they will also spread to the rest or kill themselves once they are told they have HIV.”(R5/FGD1, a 26 year old a donor and mother with 1 child).
Another participant also noted
“People don’t want to go for check- ups to know their HIV status that will hinder very many mothers from donating breast milk. And I feel if they were just taking breast milk without checkups the lines would have been very long”.(R6FGD2, 25 years old of 3 children).
Negative Cultural beliefs
Cultural beliefs and myths about breast milk donation were cited as one of the hindrances
Some of the participants noted that women will be suspicious about where exactly they are taking their breast milk and ill-intentioned people may harm the donor through breast milk donation
“Like some will be asking now they are asking for my breast milk and they take it where or do what with it? (R5/FGD4, a 30 years old mother of 3 children).
The fears and cultural beliefs were compounded by the limited information about breast milk donation.
“They will be conservative. It is something they have never heard of, they will think they are going to kill women or make them never to produce children. That kind of stuff is likely to come up as a fear from the traditional leaders. That kind of fear will be put in women and they will fear to donate milk” (R5/FGD4, a 30 years old mother of 3 children).
Health care workers also mentioned that some mothers may fear transmission of criminality such as theft, murder as well as mental illnesses through the breast milk as one of them explained:
“There are some genetic issues everything is to do with a DNA thing. Some people fear their babies to feed on the breasts of thieves, murderers, mentally disturbed people and the like, that their children will end up like that. Then another thing as Africans we respect totems, in Ankole there is a clan where by their wives can’t breast feed another person’s baby because if you do it the child will die. In Buganda I hear you don’t eat or move close to the clans or totems.”(KII1 NICU nurse, a mother and frequent breast milk Donor at st. Francis Hospital Nsambya).
The other critical aspect that was brought up through the discussions was partner refusal for mothers to donate breast milk for banking. Most women believed that their spouses would not agree to it. Some actually shared their experiences where their spouses refused them from donating as noted;
“Mine was good and supported me but others refuse their wives to donate their babies’ milk, it will be reduced and it is not enough for their baby” (KII4, frequent donor and staff at Nsambya hospital).
Another one added:
“One time my hubby asked me, don’t you think you are depleting for our baby. And I would tell him let us share. He was hesitant first but later had to allow me. But then another friend of mine the husband refused her to give his son’s milk” (Mother of one, and a frequent donor at Nsambya hospital).
However, it was noted that for some of the participants their spouses were supportive of the idea of breast milk donation which had been a great motivation for them.
“My husband was good and supported me to donate breast milk to those who were in need of it” (KII4, frequent breast milk donor at Nsambya hospital).
Suggestions to improve accepting to donate
Throughout the discussions and interactions with the participants, a number of suggestions were made on how to overcome the barriers and get women to donate breast milk to those who are in need.
Saving time for the donors by collecting breast milk from home or work place
Throughout the discussions the aspect of time was very critical as most participants wondered where they would get the time to keep going to donate breast milk since most of the potential donors are working and have other obligations to fulfil. Participants expressed the need for people to collect the milk from their homes or places of work
“How I wish there will be some people who will keep passing through to collect donated breast milk from the willing mothers. I think people should endeavor to find us at our places of work or homes” (R6/FGD2, a 25 years old mother of 3 children).
Doctors to asses those suitable to donate
The participants felt that the health workers had an important role to play in getting mothers accept to donate breast milk. They noted that health professionals were better placed to explain to the potential donors the importance of donating breast milk and to get the women to participate. They also felt that the health professionals needed to use their expertise to assess those who qualify to donate and those who don’t as one of the participants noted
“So doctors need to assess well whether the mothers have enough for their babies and then donate like they do during blood donation.”(R3/FGD1, a 33 year old mother with 3 child).
Screening breast milk donors for infections
Participants noted that some mothers may refuse the donated milk for fear of passing on infections to their children. They suggested thorough screening of the milk so that the mothers of the pre-terms can have confidence to give their babies that milk
“But I request the doctors to test so well, the donors to see that the milk is so free from any diseases. HIV has an incubation process how shall we know that the milk is so free from HIV. Let us know within what duration should a lady be tested again? Because at any time one can acquire a disease. So I pray and request that the milk is well scrutinized before it is taken to the bank to save the lives of the preterm” (R2/FGD3, 28 year old mother).
Community Education about breast milk donation
Participants noted that many people are not aware of the possibility of breast milk donation. People have many beliefs about it yet there are thousands of potential breast milk donors. They further noted that when people are sensitized about the importance of breast milk donation, they will do it
“I think ladies should be taught about it and they will be willing to donate it is about awareness creation. They need to know that some mothers lack breast milk or some preterm have lost their mothers. When they learn and see what happens in the NICU then they will be kind to donate.”(R6/FGD2, 25 years old mother of 3 children).
“Awareness creation is very important to these ladies now like my other baby I had a lot of breast milk and I would just waste it I didn’t know that some people look for breast milk for their preterm when they don’t have. I could leave it to pour so that it reduces had I known I would have come and donate”(R5/FGD4, a 30 years old mother of 3 children).
Involvement of community leaders
It was noted from the discussions that involvement of community leaders and the elderly people would facilitate the acceptance of breast milk donation. Participants noted that if the community leaders and elders understood the idea and its importance, they will influence the women to do it. Some participants noted that community leaders/elders were not conversant with formula feeds; they knew breast milk and its importance. These were considered to be facilitators if sensitized.
“Some might be young and might not understand these issues well, but traditional leaders I think will encourage us to donate some breast milk. They know the values of breast milk and always encourage us to breast feed our babies longer. So I feel what they need is sensitization and have information about donation. They will support the idea”. (R8/FGD1, 23 years old, a mother of 5 children).
“…we need to train the traditional and community leaders about breast milk donation. What they know most of is wet nursing, so we need to sensitize them and de-campaign that exercise of another mother breast feeding another’s baby and promote donation of breast milk.” (R4/FGD1, 23year old first time mother).
One of the participants shared her experience on the role of her grandmother during her experience with a premature
“I think the community leaders will buy the idea because traditional leaders know less of formulas, so they know that breast feeding is on point for babies. I had a premature baby at 7 months and I had no milk. They called my granny and they told her about it she told them that they should call my aunt and she gets tested and she helps me to get breast milk for my baby.”(R2/FGD1, 29 year old, mother of 2 children).