204 participants (51 cases and 153 controls) were included in the study after filling out a questionnaire. Cases and controls were on average 30 years old (30.12 ± 4.88 and 30 ± 4.84; respectively), had at least 1–2 pregnancies, most were housewives (cases: n = 48, 91.3%; controls: n = 129; 84.4%), and had a diploma or bachelor/higher educational attainment (cases: n = 37, 72.5%; controls: n = 137; 89.5%). The proportion of those having more than one child in the case group was 47.1% (n = 24) and in the control group was 61.4% (n = 94) (P = 0.162). 17.5% (n = 14) of mothers with a history of milk donation and 10.5% (n = 16) of mothers without a history of milk donation were employed out of home (P < 0.01). Other participants characteristics can be found in Table 1. The factors influencing mink donation to HMBs fell into four main categorical themes )physiological factors, societal attitudes and beliefs, training and motivators and accessibility( and 14 subthemes (Table 2).
Table 1
Socio-demographic characteristics of cases and controls
Demographic characteristics | Category | Case (N = 51) | Control (N = 153) | P-value | OR* | 95% CI |
n (%) | n (%) |
Number of confirmed pregnancies | One | 27 (52.90) | 59 (38.60) | 0.016 | Ref | |
Two | 21 (41.20) | 70 (45.80) | 0.66 | 0.34–1.28 |
Three | 3 (5.90) | 20 (13.10) | 0.33 | 0.09–1.20 |
Four and more | 0 (0.00) | 4 (2.60) | - | - |
Occupation | Employed | 14 (27.45) | 16 (10.50) | < 0.001 | Ref | |
Housewife | 37 (72.55) | 137 (89.50) | 0.31 | 0.14–0.69 |
Educational status | Under diploma | 13 (25.50) | 37 (24.20) | 0.580 | | |
Diploma | 22 (43.10) | 56 (36.60) | 1.12 | 0.50–2.49 |
Tertiary education | 16 (31.40) | 60 (38.20) | 0.76 | 0.33–1.76 |
Owning a personal car | Yes | 40 (78.43) | 92 (60.13) | 0.012 | 0.42 | 0.20–0.87 |
No | 11 (21.57) | 61 (39.87) | Ref | |
Owning dishwasher machine | Yes | 22 (43.10) | 45 (29.41) | < 0.001 | 0.32 | 0.16–0.61 |
No | 22 (56.90) | 108 (70.59) | Ref | |
Age | (mean ± sd) | 30.12 (4.88) | 30.65 (4.84) | 0.501 | | |
Weight | (mean ± sd) | 67.22 (10.30) | 71.55 (10.58) | 0.010 | | |
Height | (mean ± sd) | 162.94 (4.41) | 159.75 (5.36) | < 0.001 | | |
Note: sd - Standard deviation; OR – odd ratio; ref- reference category, *: dependent variable = Milk donation; Ref – reference category |
Table 2
Themes and subthemes related to factors influencing milk donation to HMBs
Themes | Subthemes |
Physiological factors | • Breastfeeding problems • The amount of breast milk • Treatment of breast pain after breastfeeding |
Societal attitudes and beliefs | • Knowledge of mothers and others • Altruism and humanity • Cultural roots and origins • Donors’ culture |
Training and motivators | • Individual motivators • Substantial motivators • Incentive mechanisms • Advertising for donation |
Accessibility | • Number of HMBs • Facilities to milk bank • Time interval to reach the milk bank • Equipping the milk bank with the most modern equipment and devices |
Note: HMB, human milk bank |
Concerning perceptions regarding human milk donation, compared to the control mothers, cases stated that they still have milk after breastfeeding more often and agreed that frequent milk expression increases the quantity of their breast milk (both P < 0.001) (Table 3). Compared to controls, cases also believed that donating milk is more physically and mentally beneficial and stated that other babies could use the donated milk (P < 0.001). According to the participants, physiological factors influenced breastfeeding, and the amount of breast milk was the most crucial factor. “A mother who has enough milk herself and produces more milk than her baby needs and has no difficulty in breastfeeding has more motivation for milk donation.” (Mother 3)
Table 3
Perceptions regarding human milk donation
Item | Category | Case (N = 51) | Control (N = 153) | P-value | OR* | 95%CI |
n (%) | n (%) |
Do you have remaining milk after breastfeeding your baby? | Rarely | 1 (1.96) | 66 (43.13) | < 0.001 | Ref | |
Sometimes | 3 (21.88) | 34 (22.22) | 5.82 | 0.58–58.13 |
Usually | 14 (27.45) | 33 (21.50) | 28.00 | 3.53-222.19 |
Most of the times | 22 (43.14) | 11 (7.17) | 132.00 | 16.11-1081.40 |
Always | 11 (21.57) | 9 (5.88) | 80.67 | 9.28-701.11 |
In addition to breastfeeding, does frequent milking increase the production of your breast milk? | Yes | 44 (81.27) | 54 (35.29) | < 0.001 | 11.52 | 4.86–27.33 |
No | 7 (18.73) | 99 (64.71) | Ref | |
Does filling your breasts make it painful? | Yes | 28 (54.90) | 61 (39.87) | 0.044 | 1.84 | 0.97–3.48 |
No | 23 (45.10) | 92 (60.13) | Ref | |
Is milk donation useful to you physically? | Low damage | 11 (21.57) | 82 (9.14) | < 0.001 | Ref | |
No losses and no benefits | 7 (13.72) | 58 (43.79) | 0.90 | 0.33–2.46 |
A lot of benefits | 21 (41.18) | 9 (5.88) | 17.39 | 6.38–47.42 |
Too many benefits | 12 (23.53) | 2 (1.31) | 44.73 | 8.82-226.89 |
I do not know | 0 (0.00) | 2 (1.31) | - | |
Is milk donation useful to you mentally? | Low damage | 10 (19.6) | 16 (10.45) | < 0.001 | Ref | |
No losses and no benefits | 5 (9.80) | 53 (34.63) | 0.15 | 0.05–0.51 |
A lot of profit | 9 (17.65) | 10 (6.53) | 1.44 | 0.43–4.77 |
Too much profit | 22 (43.14) | 11 (7.17) | 3.20 | 1.10–9.34 |
I do not know | 5 (9.80) | 62 (40.52) | 0.13 | 0.04–0.42 |
Note: * dependent variable = Milk donation; Ref – reference category |
The attitude of family and friends towards human milk donation also differed between cases and controls (Table 4). Overall, cases reported stronger support for milk donation from their spouses and family than controls (both P < 0.001). Interestingly, for both cases and controls, the encouragement from friends to donate milk to an HMB was low, particularly for controls (P < 0.001). According to the participants, family and husband’s attitudes and beliefs towards breastfeeding impacted breastmilk donation decisions. “Even though I have much milk, my mother-in-law is against donating breastmilk, and her attitude affects my husband; that is why he is also against donating milk.” (Mother 8)
Table 4
Family and friends’ attitude towards human milk donation
Item | Categories | Case (n = 51) | Control (n = 153) | P-value | OR* | 95% CI |
n (%) | n (%) |
Does your husband agree with your milk donation to HMB? | No | 5 (9.80) | 64 (41.83) | < 0.001 | Ref | |
Yes | 40 (78.43) | 17 (11.11) | 30.118 | 10.31–88.03 |
I do not know | 6 (11.77) | 72 (47.06) | 1.067 | 0.31–3.66 |
Does your family agree with your milk donation to HMB? | No | 6 (11.77) | 57 (37.25) | < 0.001 | Ref | |
Yes | 37 (72.55) | 12 (7.84) | 58.58 | 15.48-221.75 |
I do not know | 8 (15.68) | 84 (54.90) | 2.49 | 0.66–9.32 |
Until now, do your friends encourage you to donate your milk to HMB? | No | 33 (64.70) | 136 (88.89) | < 0.001 | Ref | |
Yes | 18 (35.30) | 17 (11.11) | 4.36 | 2.03–9.37 |
Note: * dependent variable = Milk donation; Ref – reference category |
The importance of about half of the health care system factors related to human milk donation differed between cases and controls (Table 5). Overall, compared to controls, cases had a greater possibility to go to an HMB, were more often offered a non-financial incentive by health workers to donate milk, agreed that milk donation was made more accessible to them by offering a milking machine (pump), and seen an advertisement about human milk donation (all P < 0.001). Despite these differences, most controls and cases stated that they were taught about milk donation during childbirth at the hospital. The majority stated that they were not taught about milk donation by a community health worker, a paediatrician, or a midwife during pregnancy. Long-distance commute, lack of a milk bank and easy access to a milk bank in cities, lack of a way to collect donated milk quickly and easily in the township were among some of the milk donation barriers. “There is only one milk bank, and it is situated in the centre of the province. If the donor is in the township, she must go to the centre of the province by using a vehicle, which is why so many mothers prefer not to donate their milk.” (Mother 7)
Table 5
Health system factors related to a human milk donation
Item | Category | Case (n = 51) | Control (n = 153) | P-value | OR* | 95% CI |
n (%) | n (%) |
How much is it possible for you to go to the milk bank? | Very low | 7 (13.72) | 72 (47.06) | 0.001˂ | Ref | |
Low | 14 (27.45) | 44 (28.76) | 3.27 | 1.23–8.74 |
Moderate | 21 (41.17) | 15 (9.80) | 14.40 | 5.19–39.95 |
Much | 8 (15.68) | 3 (1.96) | 27.43 | 5.90-127.58 |
Very much | 0 (0.00) | 1 (0.65) | - | |
I do not know | 1 (1.96) | 18 (11.76) | 0.57 | 0.07–4.95 |
Have community health workers (in your health centres) taught you about the possibility to donate milk donation? | No | 34 (66.67) | 120 (78.43) | 0 .056 | Ref | |
Yes | 17 (33.33) | 33 (21.57) | 1.82 | 0.90–3.65 |
Have your paediatrician taught you about milk donation? | No | 36 (70.59) | 137 (89.54) | 0.002 | Ref | |
Yes | 15 (29.41) | 16 (10.46) | 3.57 | 1.61–7.89 |
Have you been taught to donate milk during pregnancy by the health centre’ midwives? | No | 38 (74.51) | 135 (88.23) | 0.019 | Ref | |
Yes | 13 (25.49) | 18 (11.76) | 2.566 | 1.15–5.70 |
Have you been taught to donate milk during childbirth at the hospital? | No | 5 (9.80) | 27 (17.65) | 0.066 | Ref | |
Yes | 46 (90.20) | 126 (82.35) | 2.52 | 0.84–7.58 |
Have you ever been offered a non-financial incentive to donate milk from the milk bank? | No | 11 (21.57) | 146 (95.42) | 0.001˂ | Ref | |
Yes | 40 (78.43) | 7 (4.57) | 75.84 | 27.62-208.26 |
Does offering a milking machine by HMB make the milk donation easier for you? | No | 6 (11.77) | 22 (14.38) | 0.001˂ | ref | |
Yes | 39 (76.47) | 26 (16.99) | 38.08 | 4.85-299.15 |
I do not know | 6 (11.77) | 105 (68.63) | 1.05 | 0.12–9.41 |
Have you ever seen an advertisement about donating milk? | No | 15 (29.41) | 129 (84.31) | 0.001˂ | Ref | |
Yes | 36 (70.59) | 24 (15.69) | 12.90 | 6.13–27.13 |
Note: * dependent variable = Milk donation; Ref – reference category |
Among motivational factors that could encourage mothers to donate milk were providing the equipment needed for donations (i.e., milk pumps) and other incentives (e.g., recognition certificates, diapers, or free health checks), visiting the newborn intensive care units to inform about the benefits of breastfeeding and human milk donation, advertising human milk donation through mass media, Friday prayers, women meetings, and the distribution of informative posters. "Generally, our donors are those who are in the neonatal and newborn intensive care unit section, and they are dealing with the process of donating milk. Therefore, they understand the need for donated milk and the internal advertising is done by influential people such as the head nurse." (Senior Staff) "When mothers are trained how can they donate their milk, it encourages them to donate." (Junior Staff)
Most cultural and social factors related to human milk donation differed between cases and control (Table 6). For instance, mothers in the cases group more frequently than controls believed that milk donation does not build a family relation between the donor and a recipient, milk donation is helping others, and it will bring God’s reward. Compared to controls, cases also reported having heard about human milk donation via mass media. Participants believed that culture, society, religious and spiritual beliefs are among significant factors that influence human milk bank donation. Divine reward, altruism and humanity, helping others, making other parents happy were factors that can affect the donation of human milk. “I vowed that if my baby were born healthy, my baby would eat half of my milk, and I will give the other half to other babies.” (Mother 4) Many participants pointed out that religious beliefs such as consanguinity and kinship are among the critical barriers to milk donation. “I believe that if a mother breastfeeds a child, that a child will become consanguineous with her children, and they should not marry each other in the future.” (Mother 12)
Table 6
Cultural and social factors related to human milk donation
Item | Category | Case (n = 51) | Control (n = 153) | P-value | OR* | 95% CI |
n (%) | n (%) |
Do you see milk donation as a kind of help to others? | No | 1 (2.00) | 61 (39.90) | < 0.001 | Ref | |
Yes | 50 (98.00) | 92 (60.10) | 33.15 | 4.46-246.37 |
Does milk donation to HMB cause a family relation? | No | 41 (80.40) | 42 (27.45) | < 0.001 | Ref | |
Yes | 5 (9.80) | 39 (25.49) | 0.13 | 0.05–0.37 |
I do not know | 5 (9.80) | 72 (47.06) | 0.07 | 0.03–0.19 |
Do you believe that milk donation has a God’s reward? | No | 8 (5.90) | 60 (39.00) | < 0.001 | Ref | |
Yes | 48 (64.10) | 93 (60.80) | 10.32 | 3.08–34.64 |
Have you ever heard about milk donation in the media? | No | 32 (62.74) | 137 (89.54) | < 0.001 | Ref | |
Yes | 19 (37.25) | 16 (10.46) | 5.08 | 2.36–10.96 |
In your workplace, can you take time off to go to HMB and donate milk? | No | 8 (15.69) | 11 (7.73) | 0.140 | Ref | |
Yes | 7 (13.72) | 5 (3.77) | 1.92 | 0.44–8.33 |
Not applicable | 36 (70.59) | 137 (89.50) | - | |
Note: * dependent variable = Milk donation; Ref – reference category |
Based on the bivariate regression analysis results, the mother’s breast milk sufficiency was significantly higher in cases than the controls (P ˂0.001 for all). Also, there are no statistically significant differences in women's characteristics between cases and controls. Individual, family, social and health system factors were positively and significantly associated with milk donation (P ˂0.001 for all). Overall, the findings of qualitative and qualitative parts were in line with each other. Our quantitative and qualitative findings showed that societal attitudes and beliefs, training, motivation, and accessibility were among the most influential factors for mothers’ milk donation to HMB. Even though the quantitative findings did not show a significant relationship between physiological factors and milk donation to HMB, the physiological factors were important for milk donation to HMB, based on the mother's perspectives.