Friday, July 1, 2011

Follow-up: who should get donor milk?

So a while back I posted a question of who should be offered donor milk in the hospital. I was curious to see what people thought, and follow up with my own thoughts and current practice. I've been letting that follow-up languish, and the recent discussion about milk donation has finally nudged me into finishing it up. Here we go!

The comments were very interesting, and there seemed to be two main themes to the answers:

1) Only babies whose mothers are trying to produce breastmilk for them but are not able to (e.g. supply issues, adopted babies, etc.) should be offered donor milk

As Christie B. said:

...I have a hard time thinking that donor milk should be provided for free to women who are not trying their best to provide their own milk (if not contraindicated) for their own babies. If there is a medical issue, it makes sense for donor milk to be covered like a pharmaceutical but otherwise donor milk seems like a luxury good/service, like eating out instead of cooking.

2) Every baby should be offered donor milk as an alternative to formula, no matter the reason for supplementation (so even if mom is just not willing to breastfeed, the baby should still receive donor milk).

Burrowing In was of this mind:

As a mother whose baby was blessed by donor milk, I want to say that every baby should have access to it if necessary. Forget the mothers and their intentions and their shortcomings and their socioeconomic status. BABIES deserve that milk!

There were also ways to combine these two answers to some extent.

For example, Jespren suggested:

I feel that 1st dibs on donated breastmilk should go to NICU babies whose mothers have supply issues or have dried up and are unable to produce milk. Next I think it should be offered to mothers of healthy babies who can't physically produce any/enough milk. (This would include adopted babies whose new moms can't lactate) finally, if there is still milk availible, it should be offered to babies whose mothers chose not to breastfeed. ... But, for moms that have no physical reason not to breastfeed, they should have to purchase it, preferable at the same cost as formula. (I don't understand for a moment why DONATED breastmilk is so prohibitively expensive once it goes through a 'milk bank')*

So this prioritizes the babies who receive donor milk based on a judgment of BOTH the baby's need AND the mother's intent. Any babies whose mothers intend to breastfeed are prioritized over babies whose mothers don't intend to breastfeed.

Another comment comes from Molly who poses two questions, both of which I think are excellent:

The post's title asks two 'to whom' questions: "Who should get donor milk? Who should it be offered to?" In considering these questions, we should probably ask what 'whom's we mean: postpartum women, babies, families? You can't exactly offer a medical option to a baby, so in the second case presumably we mean the baby's parents (why only mothers, as some responses seem to suggest?). In the first question, the implication seems again to be that parents/mothers are the ones getting the milk: does it make any difference if we reconceptualize the question to mean, explicitly, 'which babies deserve access to donor milk (rather than formula)?'

This is a big piece that I struggle with. When we focus on the mother's intent, we're really asking which mothers deserve to get donor milk - not which babies. If one mother can't produce milk and one just doesn't want to, why is the first baby (not the mother) more deserving of donor milk than the second baby? Furthermore, it quickly becomes a tangled web of hairsplitting over who is "really" deserving. To tread into more politically controversial territory, over and over again I keep thinking of how it reminds me of debates on abortion and philosophical and legal attempts to determine which women are "deserving" of an abortion - women who are victims of nonconsensual sex? women who "just made a mistake this once"? etc.

In those abortion debates, I think it quickly becomes clear that it is not so much about abortion as it is deciding who is "good" and deserving of help, and who is "bad" and needs to "deal with the consequences". Similarly, trying to decide who deserves donor milk could easily be a twisty path. It's easy enough to think about a mother who says, "I'm not going to breastfeed, it's too hard, just bring me bottles of milk that some other woman has pumped" and decide that she'd be abusing the availability of donor milk, but in life, as usual, there are a lot more gray areas than black-and-white.

What about the NICU baby's mother who has a low supply, but it's low because she only pumps four times a day (knowing that she should be pumping more)? What if she only pumps four times a day because she has several other young children at home, and one has special needs? What if she's so exhausted by pumping and only getting 1/2 an ounce per session that she quits entirely? Would you feel differently if she had breastfed all of her other children for a year each, or if she had not breastfed them but had planned to breastfeed this baby, or had not planned to breastfeed this baby but changed her mind when it was born prematurely?

Or what about the mother of a healthy term baby who has a borderline supply, and has nursed and pumped diligently to keep her supply up but needs to supplement several times a day? What if she is offered medications that could bring her up to full production but declines them? Would you feel differently if she was declining them because she had a history of depression and was worried about side effects, or because she just doesn't like to take medications?

There's an element of thought experiment in some of this - in our current situation, generally only the most motivated moms who have exhausted all their resources seek out donor milk for long-term use outside of the hospital. Still, if we are aiming towards a future in which donor milk is more abundantly available to all, it's worth thinking about and examining our own assumptions about who "deserves" milk.

In the hospital, we can edge around this debate to some extent. For a healthy full-term baby the supplementation will generally be short-term (until the blood sugar stabilizes, until her milk comes in, etc.). If the mother is planning to exclusively breastfeed, we can argue that we are avoiding harmful effects on the infant gut of even a small amount of formula, assuming that soon the mother's own milk will be taking over and will be all the baby receives.

On the other hand, if the mother is planning to do some mixed feeding from very early on (as many mothers tell us they plan to do), there seems very little point in protecting the gut since they'll receive formula early on regardless.

But the way this plays out in practice makes Molly's second question very relevant:

How does class privilege play out here? Education, internet access, reading literacy, technological literacy, financial ability to purchase (and leisure time to read) books, access to high-quality mother-centered prenatal care, etc., etc.? If anyone can ASK for donor milk, should my baby get human milk simply because I'm an overeducated overprivileged English-speaking birth junkie who knows to ask the secret right question? Or, if limits on offering ought to be imposed (according to some standard of need or worth or whatever), is there any way to counteract that injustice?

Class and culture absolutely play out here, particularly in cultural terms, which are both linked to racial/ethnic background and to class. Most Hispanic moms tell us they are planning to do breast and formula, and are frequently asking for formula supplements on the first day (sometimes as soon as they come over from labor and delivery). Plans to supplement or switch to formula early are also common with African-American moms, younger moms, low-income moms... you get the idea. In fact, what the nurse asked me was whether we could offer donor milk to mothers on Medicaid. She assumed we couldn't, because she almost never saw them receiving it (just for the record, we can). She particularly wondered about why almost no Hispanic moms were ever using donor milk. But for a Hispanic baby, if we're at the point where they've lost 10% of birth weight and have not been supplemented yet, it is almost certainly because we have already deflected at least one request for formula on the part of the family over the course of the past several days.

So that's how it plays out: if we're only offering donor milk to the moms who are planning to exclusively breastfeed for at least the first couple of weeks, we end up with a real race/class imbalance of who ends up receiving donor milk. So then we tackle Molly's question of this imbalance - is it an injustice?

Part of me says yes - that everyone who asks for or needs supplementation should be offered donor milk and formula, check one. That part of me comes from knowing that there is definitely some power/educational stuff playing out here in that there is a real difference in patient vs. medical perceptions of when the baby needs to be supplemented. We, the hospital staff, have a short list of indications for supplementation, and the most common reasons are hypoglycemia and weight loss >10%. The parents have a longer list, and the most common reasons are that the baby is fussy even after breastfeeding for a long time, and the perception that the mother does not have enough milk. A mother does not necessarily plan to supplement with formula because she thinks it's better than breastmilk - she just thinks she won't have enough breastmilk (and since she has no idea that donor milk is available we have no idea if she would request that instead.) The more highly educated birth junkie types are much more aware of, and confident in, the fact that colostrum is generally all the baby needs for the first 2-3 days. They might need reassurance when the baby is fussy, but are willing to go with the medical staff's interpretation of baby's need for supplementation, whereas people from other cultural backgrounds are bringing their own perceptions of when the baby needs more.

So if we work with the families who really believe their baby needs something extra, and if we can't convince them of our worldview (that the baby is fine), do we do the baby and the family a service by offering donor milk? Does it emphasize the importance of human milk and avoiding supplementation with formula? Could it possibly help keep the mom from supplementing with formula in the future, once her milk is in? If we just accede to a request for formula without giving her the risks/benefits of both supplements available to her in the hospital, are we doing our own beliefs about the risk of formula use a disservice?

Then another part of me says, these families are very comfortable with formula use. They may be OK with donor milk and accept it in the hospital, but they are just as OK with formula and always will be. They will probably go straight to WIC for their first appointment and ask for supplemental formula. If we offer donor milk to those families, we are giving the babies a few more days of exclusive human milk feeding, but we are not really changing their overall situation that much, and we are using donor milk that could go to another baby. That's my view of the situation - is it reality, or is it just bias and perception on my part?

As you can see, I'm still struggling with this! Currently, I am sticking with only offering donor milk to babies with an indicated medical need, but I do generally discuss donor milk vs. formula for medically indicated supplementation even if the mother had previously talked about formula. Further thoughts or questions welcome!

* I think this reaction to the (prohibitive for most) cost of donor milk is fairly common. Having met and talked with people who run milk banks - the cost comes from the expenses of testing donors, paying for shipping, processing and testing the milk (which takes several time-consuming steps), sometimes space to physically host the milk bank, and of course materials and employees to do all of this. I have visited a milk bank - it was tiny! Just a couple little rooms and some very big freezers, and very committed mostly part-time employees. There seemed to be zero excess overhead going into this bank, and all HMBANA milk banks are not-for-profit. When all is said and done, there is a real cost to the shipping, safety testing and processing that donor milk goes through. If people are comfortable getting donor milk through a more informal route like Eats on Feets, they can absolutely get it cheaper (as cheap as free!), but they should understand what steps are being cut out of the process that are cutting the cost. Whether those are steps that are important to an individual mom, and/or important to every mom/baby/donor, is a whole separate discussion that I won't go into now!

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