571458
research-article2015
JHLXXX10.1177/0890334415571458Journal of Human LactationStevens and Keim
Insights in Policy
How Research on Charitable Giving Can Inform Strategies to Promote Human Milk Donations to Milk Banks
Journal of Human Lactation 1–4 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415571458 jhl.sagepub.com
Jack Stevens, PhD1,2 and Sarah A. Keim, PhD, MA, MS1,2
Abstract Many hospitalized preterm infants do not exclusively receive mother’s own milk, so milk from another mother may be sought. Previous research indicated that just 1% of US women who express breast milk actually donate it for another family. Therefore, strategies to boost donation rates should be identified. We draw upon the experimental literature on charitable giving of monetary donations to offer 6 strategies to promote breast milk donations to milk banks in North America. These strategies include (1) highlighting a potential identifiable recipient of donated breast milk as opposed to highlighting groups of potential recipients; (2) emphasizing similarities between the potential donor and potential beneficiaries; (3) emphasizing similarities between the potential donor and previous donors; (4) using negative arousal to promote donations; (5) emphasizing the self-interest of those asking for breast milk donations; and (6) highlighting the specific effect of breast milk donations. Potential limitations of these strategies are discussed. Keywords breastfeeding, charitable giving, donor milk, milk banks
Background Breast milk has significant benefits to preterm infants, which include reducing the risk of necrotizing enterocolitis (NEC).1 However, many hospitalized preterm infants do not exclusively receive mother’s own milk, so milk from another mother may be sought. Obtaining breast milk via an Internet site or other social connections is discouraged by the US Food and Drug Administration due to safety concerns of receiving unpasteurized milk from women who may not have been carefully screened for health issues.2 These safety concerns appear well-founded, as Keim and colleagues found that three-quarters of human milk samples obtained through Internet sources had high microbial levels or contamination with pathogens.3 Therefore, receiving breast milk from a milk bank is recommended on account of the thorough screening of donors, detailed shipping and handling procedures, and pasteurization required by the Human Milk Banking Association of North America.4 It is unfortunate that the milk banking system falls tens of thousands of gallons short each year in the United States alone in terms of meeting the potential demand for breast milk in preterm infants.5 These banks do not provide monetary compensation to women specifically for their breast milk to address this shortfall. Such payments could financially motivate women to misrepresent their health histories during screening, could reduce the amount of breast milk that women give their own children, or could lead women to dilute their breast milk in an effort to achieve more volume. Furthermore,
financial payments may crowd out altruistic motivations to donate breast milk and hence decrease overall milk supply, a concern that is based on the negative effect of compensation for donating blood.6 Finally, recent concerns have emerged that a for-profit company has targeted low-income minority women to sell their breast milk.7 Therefore, instead of payments, milk banks rely on donations of breast milk from women with an excessive supply. Some women may experience considerable hyperlactation, whereas other women may be regularly accumulating small amounts of milk that result in a large stockpile over months. Women in both of these groups certainly number far greater than the 1% of US women expressing milk who actually donate it.8 The surgeon general has called to “identify and address obstacles to greater availability of safe banked donor milk for fragile infants.”9(p49) Therefore, strategies to boost donation rates should be identified. We draw upon the 1
The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA Date submitted: October 29, 2014; Date accepted: January 15, 2015. Corresponding Author: Jack Stevens, PhD, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, JWest 4th Floor, Columbus, OH 43205, USA. Email: [email protected]
2 experimental literature on charitable giving of monetary donations to offer 6 strategies to promote breast milk donations to milk banks in North America. This experimental literature has featured diverse randomized studies conducted in field and university laboratory settings to identify specific factors that might encourage contributions from new and/or existing donors.
Strategies to Promote Breast Milk Donations to Milk Banks in North America Strategy 1: Highlighting a Potential Identifiable Recipient of Donated Breast Milk As Opposed to Highlighting Groups of Potential Recipients Nearly 50 years ago, Schelling10 described the identifiable victim effect, which refers to the phenomenon that people react strongly to the plight of 1 specific person. Experimental research has indicated that people judging a single donation opportunity gave more money when (a) presented with identifying information for a single beneficiary rather than when identifiers are withheld for that beneficiary and (b) presented with identifying information for a single beneficiary rather than identifying information for a group of beneficiaries.11 An individual beneficiary may be viewed as more emotionally compelling, whereas a group of potential recipients may actually lead to less emotional reactivity, a process referred to as psychic numbing.12 It is interesting that presenting simultaneously an identifiable victim with statistics about suffering at a group level may actually reduce donations versus presenting only the identifiable victim because statistics may promote more emotionally detached responses.13 Social networking sites for breast milk sharing inherently feature individual beneficiaries because requests for milk are usually posted on behalf of an individual child. Also, these social networking websites facilitate presentation of photos, stories, and other personal information that may strengthen the connection to the individual child. Furthermore, some milk bank websites highlight an individual baby who has needed breast milk donations. However, many milk bank websites do not feature such personal anecdotes and hence may benefit from highlighting such an individual story. In addition, potential breast milk advocates (eg, past donors, health care providers such as pediatricians and obstetricians/ gynecologists) who highlight the opportunity to donate may be more likely to facilitate donations if they refer potential donors to websites and materials that highlight a potential individual recipient. Of course, highlighting a potential individual beneficiary on an identifiable basis raises serious patient privacy concerns. However, these concerns are likely addressable. Parents could authorize the release of information, permitting disclosure of an individual profile. Alternately, an individual case could
Journal of Human Lactation be highlighted without using protected health information identifiers. Providing generic but not identifiable information on a specific beneficiary (eg, “Person Number 8”) has been shown to increase monetary donations relative to withholding that information.14
Strategy 2: Emphasize Similarities between the Potential Donor and Potential Beneficiaries Deborah Small15 summarized previous research indicating that reducing the social distance between a donor and recipient may increase monetary donations. Specifically, she highlighted that both perceived similarity and physical proximity to a beneficiary may lead to more contributions. When applying these findings to promoting breast milk donations, milk banks may benefit from describing individual beneficiaries in such a way that potential donors can readily recognize characteristics (eg, maternal age, residential neighborhood) they have in common with recipient families.
Strategy 3: Emphasize Similarities between the Potential Donor and Previous Donors Croson and Shang16 reviewed the experimental literature on the social influences of donations to public radio (the Corporation for Public Broadcasting) in the United States. They noted that mentioning the sex match between a recent donor and potential donor led to greater donations versus mentioning a sex mismatch. Although highlighting the sex match between a previous donor and potential donor family regarding breast milk may not be compelling because both unsurprisingly involve women, mentioning other demographic similarities like those from strategy 2 may promote donations. Similarly, encouraging a previous donor to relay her positive experiences regarding breast milk donations to her own social network, which likely constitutes individuals with similar characteristics, may foster new donors.
Strategy 4: Use Negative Arousal to Promote Donations Dickert, Sagara, and Slovic17 have suggested that experiencing negative arousal (eg, seeing the face of a distressed potential beneficiary) often increases contributions as donors seek to move toward a more positive affective state. This effect should particularly hold if the intended recipient of the assistance is viewed as blameless for his or her circumstances.18 This criterion would certainly apply to infants who, through no fault of their own, are born premature and/or unable to get breast milk. One could speculate that highlighting the negative health states of these infants (eg, showing a tiny infant in an isolette or the distended abdomen of a premature infant with NEC) may facilitate
3
Stevens and Keim donations as opposed to presenting a profile of a happy and healthy full-term infant. However, milk banks should consider eventually highlighting profiles of these infants’ recovery from their serious illnesses, as this may further increase donations. Strahilevitz19 noted that subsequent feedback on the effect of donations may foster future donations as people enjoy positive feelings at 2 points in time— when they give initially and when they learn about the specific effects of their gift.
Strategy 5: Emphasize the Positive Self-Interest of Those Asking for Breast Milk Donations Ratner, Zhao, and Clarke20 found that potential donors contribute more when the person making the request has a clear personal connection to the particular cause (eg, a fundraiser mentioning his or her relative who died from a particular disease). People may feel disheartened to decline this requester. In regard to breast milk donations, milk banks should consider featuring individual requesters with specific reasons for wanting donated breast milk, such as parents of previously hospitalized preterm infants who could not provide their own breast milk for health reasons or physicians from children’s hospitals who treat serious conditions of prematurity that may be helped by human milk. Furthermore, nonprofit milk banks may wish to highlight their not-for-profit status; their motives may be seen as particularly altruistic and favorable by potential donors relative to commercial entities that distribute donor milk products for profit.
Strategy 6: Highlight the Specific Effect of Breast Milk Donations Cryder and Loewenstein21 found that 2 factors increased charitable donations: (a) greater tangibility—mentioning specific benefits of a donation (eg, helping a low-income individual from a third world country obtain a loan to start a particular small business) as opposed to more vague benefits (eg, reducing poverty) and (b) closer goal proximity—mentioning that the next donation will help an organization reach an important milestone. Regarding the former, milk banks could frame breast milk as comparable to medicine with specific benefits (eg, reducing NEC, increasing IQ22) as opposed to mentioning more generic benefits (eg, improving health and development). Regarding the latter, milk banks could highlight when certain goals are nearly reached. For example, statements such as “We have 90% of the donated breast milk we need to save another child from a serious gastrointestinal illness” may promote donations relative to omitting this information.
Conclusion An increasingly large number of US hospitals with neonatal intensive care units are seeking donor milk.23 Whereas the strategies presented in this article are sometimes imple-
mented by milk banks in North America to meet this growing demand, donation rates may be bolstered by more consistently incorporating these tactics. These approaches could conceivably be effective in increasing both first-time and repeat donations. However, before widespread adoption of these strategies occurs, 3 potential limitations deserve mention. First, none of the aforementioned strategies has strong empirical support for increasing breast milk donations; hence, rigorous studies are needed in the future to study efficacy and potential adverse events. In particular, it is unknown if results from the aforementioned studies, some of which are based on increasing one-time monetary donations from undergraduate college students serving as research subjects, apply to longer term, nonmonetary donations such as breast milk. Also, unintended consequences of these 6 strategies, such as donors reducing their breastfeeding of their own children, should be carefully assessed. Second, although this article has focused on what milk banks can do to secure more donations, it does little good if potential donors are not even aware of the existence of milk banks in the first place. For example, health care providers may need prompts in their electronic medical records or low-cost advertisements in their clinical settings to mention that donating breast milk is even an option. Many of the strategies discussed in this article (eg, highlighting individual recipients, using negative arousal) might make such advertisements more memorable or compelling in an effort to enhance the general public’s awareness of milk donation and thereby increase monetary donations and/or milk donations to milk banks. Third, the present article does not directly address logistical barriers (eg, having time to pump excessive milk at work, reducing hassles in transporting milk24) that likely influence the availability of donated milk. Despite these limitations and given the major shortage in available donated milk, novel approaches to promoting breast milk donations may enhance current efforts to close the gap. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Boyd CA, Quigley MA, Borcklehurst P. Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2007;92(3):F169-F175. 2. US Food and Drug Administration. Science & Research Use of Donor Human Milk website. http://www.fda.gov/Science Research/SpecialTopics/PediatricTherapeuticsResearch/ucm 235203. Accessed October 27, 2014.
4 3. Keim SA, Hogan JS, McNamara KA, et al. Microbial contamination of human milk purchased via the Internet. Pediatrics. 2013;132(5):e1227-e1235. 4. Human Milk Banking Association of North America. Guidelines for the Establishment and Operation of a Donor Human Milk Bank. Fort Worth, TX: HMBANA; 2011. 5. Human Milk Banking Association of North America. How much is enough? HMBANA Matters. 2008;5:6. 6. Mellström C, Johannesson M. Crowding out in blood donation: was Titmuss right? Journal of European Economic Association. 2008;6(4):845-863. 7. Seals Allers K. Inviting African-American mothers to sell their breast milk, and profiting. New York Times. http://parenting.blogs.nytimes.com/2014/12/03/inviting-african-american-mothers-to-sell-their-breast-milk-and-profiting/?_r=0. Published December 3, 2014. Accessed January 8, 2015. 8. Labiner-Wolfe J, Fein SB, Shealy KR, Wang C. Prevalence of breast milk expression and associated factors. Pediatrics. 2008;122(S2):S63-S68. 9. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2011. 10. Schelling TC. The life you save may be your own. In: Chase SB, ed. Problems in Public Expenditure Analysis. Washington, DC: The Brookings Institute; 1968. 11. Kogut T, Ritov I. The singularity effect of identified victims in separate and joint evaluations. Organ Behav Hum Decis Process. 2005;97(2):106-116. 12. Slovic P, Zionts D, Woods AK, Goodman R, Jinks D. Psychic numbing and mass atrocity. In: Shafir E, ed. The Behavioral Foundations of Public Policy. Princeton, NJ: Princeton University Press; 2013:126-144. 13. Small DA, Loewenstein G, Slovic P. Sympathy and callousness: the impact of deliberate thought on donations to identifiable and statistical victims. Organ Behav Hum Decis Process. 2007;102(2):143-153. 14. Small DA, Loewenstein G. Helping a victim or helping the victim: altruism and identifiability. J Risk Uncertain. 2003;26(1):5-16. 15. Small DA. Sympathy biases and sympathy appeals: reducing social distance to boost charitable contributions. In: Oppenheimer DM, Olivola CY, eds. The Science of Giving:
Journal of Human Lactation Experimental Approaches to the Study of Charity. New York, NY: Psychology Press; 2011:149-160. 16. Croson R, Shang J. Social influences in giving: field experiments in public radio. In: Oppenheimer DM, Olivola CY, eds. The Science of Giving: Experimental Approaches to the Study of Charity. New York, NY: Psychology Press; 2011:65-80. 17. Dickert S, Sagara N, Slovic P. Affective motivations to help others: a two-stage model of donation decisions. In: Oppenheimer DM, Olivola CY, eds. The Science of Giving: Experimental Approaches to the Study of Charity. New York, NY: Psychology Press; 2011:161-178. 18. Loewenstein G, Small D. The scarecrow and the tin man: the vicissitudes of human sympathy and caring. Rev Gen Psychol. 2007;11(2):112-126. 19. Strahilevitz MA. A model of the value of giving to others compared to the value of having more for oneself: implications for fundraisers seeking to maximize donor satisfaction. In: Oppenheimer DM, Olivola CY, eds. The Science of Giving: Experimental Approaches to the Study of Charity. New York, NY: Psychology Press; 2011:15-34. 20. Ratner RK, Zhao M, Clarke JA. The norm of self-interest: implications for charitable giving. In: Oppenheimer DM, Olivola CY, eds. The Science of Giving: Experimental Approaches to the Study of Charity. New York, NY: Psychology Press; 2011:113-132. 21. Cryder C, Loewenstein G. The critical link between tangibility and generosity. In: Oppenheimer DM, Olivola CY, eds. The Science of Giving: Experimental Approaches to the Study of Charity. New York, NY: Psychology Press; 2011:237-251. 22. Isaacs EB, Fischl BR, Quinn BT, Chong WK, Gadian DG, Lucas A. Impact of breast milk on intelligence quotient, brain size, and white matter development. Ped Res. 2010;67(4): 357-362. 23. Parker MGK, Barrero-Castillero A, Corwin BK, Kavanagh PL, Belfort MB, Wang CJ. Pasteurized human donor milk use among US level 3 neonatal intensive care units. J Hum Lact. 2013;29(3):318-389. 24. MacKenzie C, Javanparast S, Newman L. Mothers’ knowledge of and attitudes towards human milk banking in South Australia: a qualitative analysis. J Hum Lact. 2013;29(2): 222-229.
research-article2015
JHLXXX10.1177/0890334415571458Journal of Human LactationStevens and Keim
Insights in Policy
How Research on Charitable Giving Can Inform Strategies to Promote Human Milk Donations to Milk Banks
Journal of Human Lactation 1–4 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415571458 jhl.sagepub.com
Jack Stevens, PhD1,2 and Sarah A. Keim, PhD, MA, MS1,2
Abstract Many hospitalized preterm infants do not exclusively receive mother’s own milk, so milk from another mother may be sought. Previous research indicated that just 1% of US women who express breast milk actually donate it for another family. Therefore, strategies to boost donation rates should be identified. We draw upon the experimental literature on charitable giving of monetary donations to offer 6 strategies to promote breast milk donations to milk banks in North America. These strategies include (1) highlighting a potential identifiable recipient of donated breast milk as opposed to highlighting groups of potential recipients; (2) emphasizing similarities between the potential donor and potential beneficiaries; (3) emphasizing similarities between the potential donor and previous donors; (4) using negative arousal to promote donations; (5) emphasizing the self-interest of those asking for breast milk donations; and (6) highlighting the specific effect of breast milk donations. Potential limitations of these strategies are discussed. Keywords breastfeeding, charitable giving, donor milk, milk banks
Background Breast milk has significant benefits to preterm infants, which include reducing the risk of necrotizing enterocolitis (NEC).1 However, many hospitalized preterm infants do not exclusively receive mother’s own milk, so milk from another mother may be sought. Obtaining breast milk via an Internet site or other social connections is discouraged by the US Food and Drug Administration due to safety concerns of receiving unpasteurized milk from women who may not have been carefully screened for health issues.2 These safety concerns appear well-founded, as Keim and colleagues found that three-quarters of human milk samples obtained through Internet sources had high microbial levels or contamination with pathogens.3 Therefore, receiving breast milk from a milk bank is recommended on account of the thorough screening of donors, detailed shipping and handling procedures, and pasteurization required by the Human Milk Banking Association of North America.4 It is unfortunate that the milk banking system falls tens of thousands of gallons short each year in the United States alone in terms of meeting the potential demand for breast milk in preterm infants.5 These banks do not provide monetary compensation to women specifically for their breast milk to address this shortfall. Such payments could financially motivate women to misrepresent their health histories during screening, could reduce the amount of breast milk that women give their own children, or could lead women to dilute their breast milk in an effort to achieve more volume. Furthermore,
financial payments may crowd out altruistic motivations to donate breast milk and hence decrease overall milk supply, a concern that is based on the negative effect of compensation for donating blood.6 Finally, recent concerns have emerged that a for-profit company has targeted low-income minority women to sell their breast milk.7 Therefore, instead of payments, milk banks rely on donations of breast milk from women with an excessive supply. Some women may experience considerable hyperlactation, whereas other women may be regularly accumulating small amounts of milk that result in a large stockpile over months. Women in both of these groups certainly number far greater than the 1% of US women expressing milk who actually donate it.8 The surgeon general has called to “identify and address obstacles to greater availability of safe banked donor milk for fragile infants.”9(p49) Therefore, strategies to boost donation rates should be identified. We draw upon the 1
The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA Date submitted: October 29, 2014; Date accepted: January 15, 2015. Corresponding Author: Jack Stevens, PhD, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, JWest 4th Floor, Columbus, OH 43205, USA. Email: [email protected]
2 experimental literature on charitable giving of monetary donations to offer 6 strategies to promote breast milk donations to milk banks in North America. This experimental literature has featured diverse randomized studies conducted in field and university laboratory settings to identify specific factors that might encourage contributions from new and/or existing donors.
Strategies to Promote Breast Milk Donations to Milk Banks in North America Strategy 1: Highlighting a Potential Identifiable Recipient of Donated Breast Milk As Opposed to Highlighting Groups of Potential Recipients Nearly 50 years ago, Schelling10 described the identifiable victim effect, which refers to the phenomenon that people react strongly to the plight of 1 specific person. Experimental research has indicated that people judging a single donation opportunity gave more money when (a) presented with identifying information for a single beneficiary rather than when identifiers are withheld for that beneficiary and (b) presented with identifying information for a single beneficiary rather than identifying information for a group of beneficiaries.11 An individual beneficiary may be viewed as more emotionally compelling, whereas a group of potential recipients may actually lead to less emotional reactivity, a process referred to as psychic numbing.12 It is interesting that presenting simultaneously an identifiable victim with statistics about suffering at a group level may actually reduce donations versus presenting only the identifiable victim because statistics may promote more emotionally detached responses.13 Social networking sites for breast milk sharing inherently feature individual beneficiaries because requests for milk are usually posted on behalf of an individual child. Also, these social networking websites facilitate presentation of photos, stories, and other personal information that may strengthen the connection to the individual child. Furthermore, some milk bank websites highlight an individual baby who has needed breast milk donations. However, many milk bank websites do not feature such personal anecdotes and hence may benefit from highlighting such an individual story. In addition, potential breast milk advocates (eg, past donors, health care providers such as pediatricians and obstetricians/ gynecologists) who highlight the opportunity to donate may be more likely to facilitate donations if they refer potential donors to websites and materials that highlight a potential individual recipient. Of course, highlighting a potential individual beneficiary on an identifiable basis raises serious patient privacy concerns. However, these concerns are likely addressable. Parents could authorize the release of information, permitting disclosure of an individual profile. Alternately, an individual case could
Journal of Human Lactation be highlighted without using protected health information identifiers. Providing generic but not identifiable information on a specific beneficiary (eg, “Person Number 8”) has been shown to increase monetary donations relative to withholding that information.14
Strategy 2: Emphasize Similarities between the Potential Donor and Potential Beneficiaries Deborah Small15 summarized previous research indicating that reducing the social distance between a donor and recipient may increase monetary donations. Specifically, she highlighted that both perceived similarity and physical proximity to a beneficiary may lead to more contributions. When applying these findings to promoting breast milk donations, milk banks may benefit from describing individual beneficiaries in such a way that potential donors can readily recognize characteristics (eg, maternal age, residential neighborhood) they have in common with recipient families.
Strategy 3: Emphasize Similarities between the Potential Donor and Previous Donors Croson and Shang16 reviewed the experimental literature on the social influences of donations to public radio (the Corporation for Public Broadcasting) in the United States. They noted that mentioning the sex match between a recent donor and potential donor led to greater donations versus mentioning a sex mismatch. Although highlighting the sex match between a previous donor and potential donor family regarding breast milk may not be compelling because both unsurprisingly involve women, mentioning other demographic similarities like those from strategy 2 may promote donations. Similarly, encouraging a previous donor to relay her positive experiences regarding breast milk donations to her own social network, which likely constitutes individuals with similar characteristics, may foster new donors.
Strategy 4: Use Negative Arousal to Promote Donations Dickert, Sagara, and Slovic17 have suggested that experiencing negative arousal (eg, seeing the face of a distressed potential beneficiary) often increases contributions as donors seek to move toward a more positive affective state. This effect should particularly hold if the intended recipient of the assistance is viewed as blameless for his or her circumstances.18 This criterion would certainly apply to infants who, through no fault of their own, are born premature and/or unable to get breast milk. One could speculate that highlighting the negative health states of these infants (eg, showing a tiny infant in an isolette or the distended abdomen of a premature infant with NEC) may facilitate
3
Stevens and Keim donations as opposed to presenting a profile of a happy and healthy full-term infant. However, milk banks should consider eventually highlighting profiles of these infants’ recovery from their serious illnesses, as this may further increase donations. Strahilevitz19 noted that subsequent feedback on the effect of donations may foster future donations as people enjoy positive feelings at 2 points in time— when they give initially and when they learn about the specific effects of their gift.
Strategy 5: Emphasize the Positive Self-Interest of Those Asking for Breast Milk Donations Ratner, Zhao, and Clarke20 found that potential donors contribute more when the person making the request has a clear personal connection to the particular cause (eg, a fundraiser mentioning his or her relative who died from a particular disease). People may feel disheartened to decline this requester. In regard to breast milk donations, milk banks should consider featuring individual requesters with specific reasons for wanting donated breast milk, such as parents of previously hospitalized preterm infants who could not provide their own breast milk for health reasons or physicians from children’s hospitals who treat serious conditions of prematurity that may be helped by human milk. Furthermore, nonprofit milk banks may wish to highlight their not-for-profit status; their motives may be seen as particularly altruistic and favorable by potential donors relative to commercial entities that distribute donor milk products for profit.
Strategy 6: Highlight the Specific Effect of Breast Milk Donations Cryder and Loewenstein21 found that 2 factors increased charitable donations: (a) greater tangibility—mentioning specific benefits of a donation (eg, helping a low-income individual from a third world country obtain a loan to start a particular small business) as opposed to more vague benefits (eg, reducing poverty) and (b) closer goal proximity—mentioning that the next donation will help an organization reach an important milestone. Regarding the former, milk banks could frame breast milk as comparable to medicine with specific benefits (eg, reducing NEC, increasing IQ22) as opposed to mentioning more generic benefits (eg, improving health and development). Regarding the latter, milk banks could highlight when certain goals are nearly reached. For example, statements such as “We have 90% of the donated breast milk we need to save another child from a serious gastrointestinal illness” may promote donations relative to omitting this information.
Conclusion An increasingly large number of US hospitals with neonatal intensive care units are seeking donor milk.23 Whereas the strategies presented in this article are sometimes imple-
mented by milk banks in North America to meet this growing demand, donation rates may be bolstered by more consistently incorporating these tactics. These approaches could conceivably be effective in increasing both first-time and repeat donations. However, before widespread adoption of these strategies occurs, 3 potential limitations deserve mention. First, none of the aforementioned strategies has strong empirical support for increasing breast milk donations; hence, rigorous studies are needed in the future to study efficacy and potential adverse events. In particular, it is unknown if results from the aforementioned studies, some of which are based on increasing one-time monetary donations from undergraduate college students serving as research subjects, apply to longer term, nonmonetary donations such as breast milk. Also, unintended consequences of these 6 strategies, such as donors reducing their breastfeeding of their own children, should be carefully assessed. Second, although this article has focused on what milk banks can do to secure more donations, it does little good if potential donors are not even aware of the existence of milk banks in the first place. For example, health care providers may need prompts in their electronic medical records or low-cost advertisements in their clinical settings to mention that donating breast milk is even an option. Many of the strategies discussed in this article (eg, highlighting individual recipients, using negative arousal) might make such advertisements more memorable or compelling in an effort to enhance the general public’s awareness of milk donation and thereby increase monetary donations and/or milk donations to milk banks. Third, the present article does not directly address logistical barriers (eg, having time to pump excessive milk at work, reducing hassles in transporting milk24) that likely influence the availability of donated milk. Despite these limitations and given the major shortage in available donated milk, novel approaches to promoting breast milk donations may enhance current efforts to close the gap. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Boyd CA, Quigley MA, Borcklehurst P. Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2007;92(3):F169-F175. 2. US Food and Drug Administration. Science & Research Use of Donor Human Milk website. http://www.fda.gov/Science Research/SpecialTopics/PediatricTherapeuticsResearch/ucm 235203. Accessed October 27, 2014.
4 3. Keim SA, Hogan JS, McNamara KA, et al. Microbial contamination of human milk purchased via the Internet. Pediatrics. 2013;132(5):e1227-e1235. 4. Human Milk Banking Association of North America. Guidelines for the Establishment and Operation of a Donor Human Milk Bank. Fort Worth, TX: HMBANA; 2011. 5. Human Milk Banking Association of North America. How much is enough? HMBANA Matters. 2008;5:6. 6. Mellström C, Johannesson M. Crowding out in blood donation: was Titmuss right? Journal of European Economic Association. 2008;6(4):845-863. 7. Seals Allers K. Inviting African-American mothers to sell their breast milk, and profiting. New York Times. http://parenting.blogs.nytimes.com/2014/12/03/inviting-african-american-mothers-to-sell-their-breast-milk-and-profiting/?_r=0. Published December 3, 2014. Accessed January 8, 2015. 8. Labiner-Wolfe J, Fein SB, Shealy KR, Wang C. Prevalence of breast milk expression and associated factors. Pediatrics. 2008;122(S2):S63-S68. 9. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2011. 10. Schelling TC. The life you save may be your own. In: Chase SB, ed. Problems in Public Expenditure Analysis. Washington, DC: The Brookings Institute; 1968. 11. Kogut T, Ritov I. The singularity effect of identified victims in separate and joint evaluations. Organ Behav Hum Decis Process. 2005;97(2):106-116. 12. Slovic P, Zionts D, Woods AK, Goodman R, Jinks D. Psychic numbing and mass atrocity. In: Shafir E, ed. The Behavioral Foundations of Public Policy. Princeton, NJ: Princeton University Press; 2013:126-144. 13. Small DA, Loewenstein G, Slovic P. Sympathy and callousness: the impact of deliberate thought on donations to identifiable and statistical victims. Organ Behav Hum Decis Process. 2007;102(2):143-153. 14. Small DA, Loewenstein G. Helping a victim or helping the victim: altruism and identifiability. J Risk Uncertain. 2003;26(1):5-16. 15. Small DA. Sympathy biases and sympathy appeals: reducing social distance to boost charitable contributions. In: Oppenheimer DM, Olivola CY, eds. The Science of Giving:
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