BREASTFEEDING MEDICINE Volume 9, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2014.0009
‘‘I’m Happy to Be Able to Help:’’ Why Women Donate Milk to a Peer via Internet-Based Milk Sharing Networks Karleen D. Gribble
Abstract
The process by which women came to donate milk via online milk sharing networks was explored via a questionnaire administered to 97 peer milk donors. Seventy-one respondents stated that they were motivated to donate milk because they wanted to help someone. Many described milk donation as an empathic response to women with insufficient milk. Seventy-four respondents donated milk that they had previously expressed but did not need. Their desire to ensure that their milk was not wasted contributed to their decision to donate. Fiftyone respondents expressed milk specifically for donation, including 20 donors who initially donated previously expressed surplus milk but then expressed milk specifically for recipient peers. The motivations of peer-to-peer donors are the same as those reported for women donating to a milk bank. Respondents who donated previously expressed milk had originally expressed so they had milk when separated from their baby, to manage an overabundant milk supply, because their baby was unwilling or unable to breastfeed, in case of emergency, and to maintain milk supply. This study is the first to clearly identify that some women express milk because they believe this is required for milk supply maintenance. Peer milk donors appeared satisfied with their experience of donating milk. The importance of altruistic motivation should be considered in discussions of the desirability of financial compensation for milk donation. Further research is needed on why women express their milk and whether such expression is beneficial to them.
Introduction
P
eer-to-peer milk sharing involves the donation of expressed breastmilk by one woman to another woman for the purpose of feeding the second woman’s infant. Until recently such arrangements occurred sporadically because they required women with milk to share to have knowledge of the need of another for breastmilk. Because the sharing of breastmilk transgresses social norms and is often culturally unacceptable (e.g., Australia, New Zealand, and the United States), the dissemination of such knowledge was constrained.1–3 However, in 2011 social media was used to establish networks where individuals in need of milk and women with milk to share can advertise their desire to donate, or need for, milk. This has allowed the widespread facilitation of milk sharing between women previously unknown to one another. The gifting of milk by one mother to another mother’s infant is not a new phenomenon. Prior to the easy availability of refrigeration, such sharing was predominantly facilitated via wet nursing. Although wet nursing was often a paid oc-
cupation, unrenumerated wet nursing also occurred (e.g., Wolf 4). Since the beginning of the 20th century, sharing of expressed breastmilk via donor milk banks has provided human milk to sick infants. Although for much of the history of milk banks, donors received financial compensation, unpaid donations currently predominate.5 The current movement of peer-to-peer milk sharing shares characteristics of wet nursing and milk banking. In common with the former, the donation is a relationship-based action where individuals contract directly with one another. In common with the latter, it is expressed breastmilk that is shared. Descriptions of motivations for unpaid wet nursing are scant. Thorley6 described women with engorged breasts wetnursing infants whose mothers had insufficient milk or infants awaiting adoption, on the request of health providers. Krantz and Kupper,7 Fildes,8 and Shaw2 described friends breastfeeding each other’s infants for ‘‘mutual advantage’’ in sharing the work of infant care and allowing mothers to be involved in other activities. Finally, letters to the Nursing Mothers’ Association of Australia Newsletter described wet nursing between friends or relatives in sharing infant care,
School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia.
251
252
when a mother is unexpectedly absent or unable to breastfeed because of illness, and to assist in overcoming breastfeeding difficulties.9 Motivations for donating to milk banks have been the subject of research. Azema and Callahan10 found that women donated to a milk bank primarily because they had too much milk themselves and because they wished to help someone else. Pimenteira Thomaz et al.11 found that women decided to donate after it was suggested by a health professional, because they knew of the need for donor milk, and because they felt it was a social responsibility. Osbaldiston and Mingle12 found that women donated to help others because they had too much milk, knew that donations were needed, hoped that someone would do the same for them, and felt they needed to pump ‘‘to stimulate lactation.’’ The motivation and processes by which women donate expressed breastmilk to another woman has not previously been considered. This study sought to examine the motivation and processes by which women came to donate milk to a peer via the Internet. Materials and Methods
The study used a descriptive survey design containing closed and open-ended questions to examine the beliefs and practices of individuals involved in peer-to-peer milk sharing. A convenience sample of peer-to-peer milk donors and recipients was recruited via advertisement on the Facebook pages of the Internet-based milk sharing groups Human Milk 4 Human Babies and Eats on Feets. To be eligible to participate, individuals were required to have donated or received breastmilk in the previous 6 months in an arrangement that was facilitated via the Internet. Advertisements for the study directed individuals meeting the inclusion criteria to e-mail the study author. Individuals were e-mailed a letter outlining the method, background, and purpose of the study. Those who wished to participate were directed to request a copy of the study questionnaire, which contained 28 mostly open-ended questions. Ninety-one percent of peer milk donors who requested the study questionnaire returned a completed questionnaire. Ethics approval was obtained from the University of Western Sydney Human Research Ethics Committee. The results pertaining to reasons for donating milk to a peer are presented here. Respondents were asked questions about why they had donated milk to a peer and whether they donated previously expressed milk or had expressed milk specifically for donation. If they had previously expressed milk, they were asked why they had expressed this milk. They were also asked whether they would donate milk to a peer again. Closed-ended questions were analyzed using descriptive statistics, and conventional qualitative content analysis was used to analyze open-ended responses.13 Questionnaire responses were read, reread, and initially coded to reveal recurring themes. Codes that were conceptually similar were combined, as appropriate. Results
Ninety-seven milk donors from North America, Europe, Oceania, and Asia participated in the study. Donors ranged in age from 21 to 43 years, had from one to four children, and had previous breastfeeding experience of from 4 to 120
GRIBBLE
months. The child of the most recent lactation was from 0 to 17 months old. Donors had from one to nine recipients to whom they had donated 2–216 L. A summary of the characteristics of respondents is shown in Table 1. The reasons for donating milk were predominantly altruistic and practical. Altruistic motivation was the most prominent, as 73% of respondents stated they donated milk because they wanted to help someone: for example, ‘‘I’ve been very blessed with an ample milk supply and wanted to use this blessing to help another mama/baby.’’ Contributors to this altruistic motivation were evident in many responses. For some, prior experience with wet nursing, milk sharing, or insufficient milk had supported their decision to donate: for example, ‘‘I fully supplemented my baby sister for several months while my mother [was sick].. This sparked my interest in milk sharing’’ and ‘‘Some of my motivation stems from the fact that I had a very hard time nursing my first child. I didn’t even know that donor breastmilk was an option.’’ For others, hearing about an individual’s need was a catalyst: ‘‘I read an article about a mother who could not nurse because of health problems and her son was allergic to formula.. I couldn’t imagine having that happen and the feelings of helplessness. So I looked into donating.’’ As in the previous response, donors commonly placed themselves in the situation of women who were not able to fully breastfeed. Thus, their reasons for donating milk included an understanding that not everyone could make enough milk, an appreciation of how fortunate they were, and also how they would feel if they had insufficient milk: for example, ‘‘I’m extremely lucky that breastfeeding came easily to me.and that I have ample supply. I know that this is often not the case for others.. I figured that I had excess of what other people so desperately wished they had, so why not donate mine to them?’’ Respondents also stated that they would want someone to donate to them if they didn’t have enough: thus, ‘‘I just felt for mothers who wanted to breastfeed, but were unable for whatever reason.. If I were in that situation, I would want someone to help me out.’’ The practical motivation for women donating milk to a peer was evident in the 60% of respondents who stated they donated because they had excess milk production or unneeded expressed milk: for example, ‘‘I had so much excess milk [in the freezer] that I just knew I wouldn’t use’’ and ‘‘I had an excess of milk, due to oversupply, and I began expressing it and freezing it.’’ It was important to respondents with excess expressed milk that their milk not be wasted. As
Table 1. Characteristics of Donor Respondents Donors’ characteristics Age (years) Number of children Age (months) of child of most recent lactation Duration (months) of previous breastfeeding experience Number of recipients Volume (L) of milk donated
Mean
Standard deviation
30 (n = 97) 1.7 (n = 97) 3.2 (n = 93)
4.2 0.82 3.5
21 (n = 93)
18.0
2.1 (n = 97) 26 (n = 88)
1.7 39.4
WHY WOMEN DONATE MILK TO A PEER
253
stated by one respondent, ‘‘I was not about to throw that precious milk away.’’ Respondents also described how they donated their milk because they had an abundance of milk to give: ‘‘I had a very easy time producing breastmilk and wanted to help out.’’ A few respondents noted that donation to a milk bank was not possible, practical, or acceptable to them and also that they found milk expression easy. Many respondents expressed a belief that breastmilk is important or that infant formula is deficient: for example, ‘‘I think that breastmilk is an extremely important part of the growth and development of a child and every parent should have the option.to provide this to their infant.’’ Such beliefs supported both practical and altruistic motivations for donation. A summary of these results is shown in Table 2. The majority of respondents (76%) donated previously expressed surplus breastmilk: for example, ‘‘[I had] a very big freezer stash that needed to be used before it spoiled. I didn’t need it as my daughter had plenty of ‘fresh’ milk.’’ Others expressed specifically so that they could give the expressed milk to a peer: ‘‘I express milk to donate, and have worked to increase my supply so I can provide this to another baby.’’ Many women became involved in peer-to-peer milk sharing by donating surplus, previously expressed breastmilk and then continued to express milk specifically for donation. Of the 28 respondents who donated previously expressed breastmilk and expressed specifically for donation, 20 stated that they had started by donating their previously expressed milk but had then decided to express milk just to donate: for example, ‘‘Initially it was surplus
Table 2. Reasons for Donor Respondents Deciding to Donate Milk via Peer-to-Peer Milk Sharing Category of response Wanted to help a child/mother/family who needed milk Had expressed milk or excess milk that my child didn’t need Didn’t want expressed milk to go to waste Think breastmilk is important/view infant formula as deficient Made plenty of milk myself Was inspired by an individual’s story Know not everyone can make enough milk/feel luck to make enough milk/would feel terrible if I couldn’t make enough Would want someone to give me milk if I couldn’t make enough Previous experience with wet nursing/milk sharing Previous experience with insufficient milk Too difficult/not possible/didn’t want to donate to a milk bank Object to the costs charged by milk banks Find expressing easy
Frequency (n = 97) 71 59
Table 3. Type of Milk Donated by Donor Respondents Category of response Donated surplus expressed milk Expressed to donate Both surplus and milk expressed for donating
Frequency (n = 97) 74 51 28
[milk], then I pumped especially for the mother.’’ Results are shown in Table 3. The reasons why donor respondents had stored breastmilk to donate were explored. The most common reason by far was because they were physically separated from their infant while working: ‘‘[I expressed] so my son would have milk while I was at work.’’ It was also common to have expressed milk because of an oversupply of milk: ‘‘I have had an oversupply.. I began expressing my surplus of milk for comfort.’’ Many respondents expressed milk so that their baby could receive breastmilk if they were unexpectedly separated: ‘‘I wanted to have a small ‘‘emergency supply’’ in my freezer.’’ Some respondents felt that they needed to express to maintain their milk supply: ‘‘I express an extra feeding a day to keep up my milk supply.’’ Some respondents stated that they were exclusively expressing for their own baby who was unwilling or unable to breastfeed in the short or long term, or so that their baby could have their milk when they were away from them: for example, ‘‘Child is 100% tube fed, so I pump exclusively,’’ ‘‘My daughter had issues with latch for the first 3½ weeks of her life.. As a result, I was pumping,’’ and ‘‘[I expressed milk] to feed my son while I was out.’’ Less common reasons for expressing milk were so that the respondent’s partner could feed the baby, so that there was stored milk to feed the baby after breastfeeding had ceased, to mix with solid food, and as a mastitis treatment. A summary of results is shown in Table 4. When asked if they would donate milk to a peer again, 95 respondents stated that they would. Twenty noted that they were currently donating milk to a peer, one stated that she would also donate to a milk bank, and a further respondent
37 33 27 15 12
9 9 5 4 3 2
Table 4. Why Donor Respondents Had Previously Expressed Milk Category of response For while separated from baby because of work To deal with oversupply In case of emergency Maintain milk supply Baby unwilling or unable to breastfeed in the long term For when away from baby Baby unwilling or unable to breastfeed in the short term For partner to feed to baby To feed after breastfeeding had ceased Mix with solid food Treatment for mastitis
Frequency (n = 66) 29 14 9 7 6 5 5 3 2 1 1
254
stated that she would donate again but that she needed to keep track of milk kinship relationships. Two respondents stated that they might donate depending on the circumstances. Discussion
The desire to help another woman and her child motivated nearly three-quarters of peer milk donors. Donation via peer networks meets the definition of classical altruism in being a behavior that benefits an unrelated person while costing the individual performing the act.14 The actions of donors who donated partially because they hoped that someone would help them if they needed milk could be described as a type of reciprocal altruism.14 Donation as an empathic response was also evident in donors who described thinking processes where they had ‘‘put themselves in the shoes’’ of women who could not fully breastfeed.15 Although most respondents donated milk that they had previously expressed for other reasons, many expressed breastmilk specifically for donation. It was the circumstances of women who had insufficient milk that motivated expression and donation of milk. However, more than a quarter of women who had initially engaged in milk sharing by donating their surplus expressed breastmilk continued to express milk specifically for donation. Respondents stated that it was the circumstances of the recipient and knowing her and her child that motivated them to continue donating. As identified previously, the specific knowledge of the need for milk can make additional expressed breastmilk available.16 Good feelings after donation may have also encouraged women to express additional milk for donation. Other research has identified that giving to help others increases donors’ feelings of well-being and contributes to continued donation.17,18 This response has been identified in blood donation and may also apply in milk donation.18 It has been argued that donations providing this ‘‘feel good’’ reaction should be considered as benevolence rather than pure altruism.18 Regardless, that donors can produce additional milk in response to the context of donation suggests that breastmilk can be viewed as a renewable, rather than a limited, resource. More than half of respondents donated expressed breastmilk that their infant did not require, and most did so because they did not want milk to be wasted. As noted elsewhere, peer-to-peer milk donors highly value their milk. This value is derived from the work of expressing milk, understanding of the importance of breastmilk and their view of breastmilk as a part of themselves.16 Peer-to-peer milk sharing enabled meaningful use of their breastmilk. In describing the ideal human milk bank donor, Arnold and Borman19 nominate, as characteristic, (1) a desire to help another infant or child and (2) an unwillingness to waste expressed milk. One or both of these motivations underlaid why donor respondents donated their milk. It has been identified that peer-to-peer milk donors differ in important ways from milk bank donors in terms of eligibility, philosophy of milk donation, and the need to know recipients’ circumstances.16 However, they do not appear to differ in terms of motivation to donate. All reasons for donation reported by respondents had previously been reported as motivating milk bank donors.10–12 Peer-to-peer milk donors also show a similarly high level of satisfaction with donating as milk bank donors.12
GRIBBLE
The motivations underlying donation of human tissues, such as blood, are recognized as influencing the safety of the donation.20 Research has revealed that altruistic blood donation provides the highest level of safety.21 It has been proposed that in order to increase donation to milk banks, milk donors should be paid.22 Payment for milk may undermine the altruistic motivation of donation and decrease the quality and volume of donations. Recent research has identified that purchased human milk has high levels of bacterial contamination.23,24 Before a decision is made to pay women for milk bank donations, the experiences of blood banks with payment of donors should be considered. That many respondents had excess expressed milk to donate is of interest. The expression of breastmilk is increasingly common. For example, in the United States, the Infant Feeding Practices II Study found that 85% of breastfeeding women had expressed breastmilk.25 In Perth, Australia, the proportion of mothers expressing breastmilk increased from 38% to 69% between 1993 and 2003.26 The increasing incidence of milk expression has been linked to the easy availability of breast pumps, questionable marketing of pump manufacturers, and increased participation of women in the waged workforce.27,28 In many countries, breast pumps are now considered to be a ‘‘necessity’’ of modern motherhood.27 For example, in the United States, health insurers are required by law to provide new mothers with a breast pump.27,29 However, the degree to which the ubiquity of breast pumps assists or hampers breastfeeding women has yet to be ascertained.30 The reasons given by respondents for expressing milk have largely been identified in the general population of women who express milk. For example, maternal employment, overproduction of milk, in case of an emergency, because an infant is unable or unwilling to breastfeed, for when separated from the baby, for someone else to feed the baby, and to mix with solid food have all previously been identified as reasons for milk expression.31–34 Expressing milk in order to maintain a milk supply has not been clearly identified previously. This is perhaps because studies of milk expression have provided a checklist of reasons for milk expression rather than allowing women to use their own words to describe why they had expressed milk. However, there is some evidence suggesting that women expressing milk to maintain a milk supply is not anomalous. Osbaldiston and Mingle12 found that a percentage of milk bank donors indicated in a checklist that they expressed milk ‘‘to stimulate lactation.’’ The meaning of this phrase is unclear. It could describe women with low milk supply expressing to increase milk production. However, this group of women were high-volume donors, suggesting that they were expressing milk in excess of requirements. Similarly, Geraghty et al.,35 in a study of breastfeeding practice, found that some women ‘‘overproduced’’ via milk expression. Thus, it seems that it may be common for women with sufficient milk to express to excess. Milk production is a supply and demand process, and in the absence of physiological abnormalities, breasts will make the milk required in response to milk removal by the baby.36 However, women commonly believe that they do not make enough milk (e.g., Hillervik-Lindquist37), which often leads to cessation of breastfeeding or introduction of infant formula.38 Expressing milk ‘‘to maintain milk supply’’ may be a new response to perceived insufficient milk. The belief that
WHY WOMEN DONATE MILK TO A PEER
expressing milk is necessary may flow from baby books that include expressing sessions in their ‘‘breastfeeding schedules.’’39,40 Finally, the use of breast pumps in situations for which a clinical indication is lacking is concerning.31 Although an increase in the production and expression of milk is a boon to milk banks and individuals in need of milk for their infant, this trend should not be considered unquestioningly good. Previous research has identified that mothers commonly use expression to help them overcome problems with breastfeeding.26 However, there is some question as to whether this is always beneficial. For example, women may eschew breastfeeding and pump and bottle feed their milk because they are experiencing nipple pain.32 Milk expression may be easier than obtaining skilled breastfeeding assistance, but ultimately not provide a solution and result in early weaning. Similarly, the expectation that women can combine breastfeeding and work via milk expression may undermine other solutions such as paid maternity leave or onsite childcare.41,42 Finally, although Osbaldiston and Mingle12 suggested that women who are expressing to ‘‘stimulate their milk supply’’ should be actively targeted for recruitment as milk donors, it is questionable whether this is appropriate. Rather, such women may benefit from support and assistance concerning their likely ability to breastfeed without the need for additional expression. Conclusions
In common with milk bank donors, peer-to-peer milk donors donate their milk primarily because they want to help and because they do not want their expressed milk to be wasted. Such motivations are protective factors for those seeking milk from a peer. Individuals considering the purchase of breastmilk should consider how the motivation of milk sellers might vary from that of milk donors and how this might impact milk quality. Further research into milk expression is needed to better understand whether milk expression is occurring unnecessarily or to the detriment of mothers and infants. Acknowledgments
The author thanks the women who so kindly shared their experiences and the administrators of the Human Milk 4 Human Babies and Eats on Feets Facebook pages who assisted with participant recruitment. References
1. Thorley V. Mothers’ experiences of sharing breastfeeding or breastmilk co-feeding in Australia 1978–2008. Breastfeed Rev 2009;17:9–18. 2. Shaw R. Virtues of cross-nursing and the ’yuk factor.’ Aust Feminist Stud 2004;19:287–299. 3. Bar-Yam NB. Sharing breastfeeding: The experience of cross nursing among mothers in the United States. Birth Issues 2005;14:57–63. 4. Wolf JH. ‘‘Mercenary hirelings’’ or ‘‘a great blessing’’?: Doctors’ and mothers’ conflicted perceptions of wet nurses and the ramifications for infant feeding in Chicago, 1871– 1961. J Soc History 1999;33:97. 5. Golden J. From commodity to gift: Gender, class and the meaning of breastmilk in the 20th-century. Historian 1996;59:75–87.
255
6. Thorley V. Human milk use in Australian hospitals, 1949– 1985. Breastfeed Rev 2012;20:13–23. 7. Krantz JZ, Kupper NS. Cross-nursing: Wet-nursing in a contemporary context. Pediatrics 1981;67:715–717. 8. Fildes V. Wet Nursing: A History from Antiquity to the Present. Blackwell Publishers, Oxford, United Kingdom, 1988. 9. Michael M, Faraj J, Wlicox K, et al. Wet nursing. Nurs Mothers Assoc Aust 1994;30:13–18. 10. Azema E, Callahan S. Breast milk donors in France: A portrait of the typical donor and the utility of milk banking in the French breastfeeding context. J Hum Lact 2003;19:199–202. 11. Pimenteira Thomaz AC, Maia Loureiro LV, da Silva Oliveira T, et al. The human milk donation experience: Motives, influencing factors, and regular donation. J Hum Lact 2008;24:69–76. 12. Osbaldiston R, Mingle LA. Characterization of human milk donors. J Hum Lact 2007;23:350–357. 13. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277–1288. 14. Fehr E, Fischbacher U. The nature of human altruism. Nature 2003;425:785–791. 15. Hein G, Singer T. I feel how you feel but not always: The empathic brain and its modulation. Curr Opin Neurobiol 2008;18:153–158. 16. Gribble K. Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks. J Obstet Gynecol Neonatal Nurs 2013;42:451–461. 17. Anik L, Aknin LB, Norton MI, et al. Feeling good about giving: The benefits (and costs) of self-interested charitable behavior. Harvard Business School Market Work Paper 2009;No. 10-012. 18. Ferguson E, Farrell K, Lawrence C. Blood donation is an act of benevolence rather than altruism. Health Psychol 2008;27:327–336. 19. Arnold LDW, Borman LL. What are the characteristics of the ideal human milk donor? J Hum Lact 1996;12:143–145. 20. Titmuss RM. The Gift Relationship: From Human Blood to Social Policy. New Press, New York, 1997. 21. Wylie B. Which methods of donor recruitment give the safest donors? Malay J Pathol 1993;15:99–103. 22. Medo ET. Increasing the global supply and affordability of donor milk. Breastfeed Med 2013;8:438–441. 23. Keim SA, Hogan JS, McNamara KA, et al. Microbial contamination of human milk purchased via the Internet. Pediatrics 2013;132:e1227–e1235. 24. Geraghty SR, McNamara KA, Dillon CE, et al. Buying human milk via the Internet: Just a click away. Breastfeed Med 2013;8:474–478. 25. Labiner-Wolfe J, Fein SB, Shealy KR, Wang C. Prevalence of breast milk expression and associated factors. Pediatrics 2008;122(Suppl 2): S63–S68. 26. Binns CW, Win NN, Zhao Y, et al. Trends in the expression of breastmilk 1993–2003. Breastfeed Rev 2006;14:5–9. 27. Martucci J. Breast pumping. Virtual Mentor 2013;15:791– 797. 28. Van Esterik P. Expressing ourselves: Breast pumps. J Hum Lact 1996;12:273–274. 29. Drago R, Hayes J, Yi Y. Better Health for Mothers and Children: Breastfeeding Accommodations Under the Affordable Care Act. Institute for Women’s Policy Research, Washington, DC, 2010. 30. Rasmussen KM, Geraghty SR. The quiet revolution: Breastfeeding transformed with the use of breast pumps. Am J Public Health 2011;101:1356–1359.
256
31. Clemons SN, Amir LH. Breastfeeding women’s experience of expressing: A descriptive study. J Hum Lact 2010;26: 258–265. 32. Johnson S, Leeming D, Williamson I, Lyttle S. Maintaining the ’good maternal body’: Expressing milk as a way of negotiating the demands and dilemmas of early infant feeding. J Adv Nurs 2012;69:590–599. 33. Sisk P, Quandt S, Parson N, et al. Breast milk expression and maintenance in mothers of very low birth weight infants: Supports and barriers. J Hum Lact 2010;26: 368–375. 34. Labiner-Wolfe J, Fein SB, Shealy KR, et al. Prevalence of breast milk expression and associated factors. Pediatrics 2008;122(Suppl 2):S63–S68. 35. Geraghty SR, Sucharew H, Rasmussen KM. Trends in breastfeeding: It is not only at the breast anymore. Matern Child Nutr 2013;9:180–187. 36. Kent JC. How breastfeeding works. J Midwifery Womens Health 2007;52:564–570. 37. Hillervik-Lindquist C. Studies on perceived breast milk insufficiency. A prospective study in a group of Swedish women. Acta Paediatr Scand Suppl 1991;376:1–27.
GRIBBLE
38. Gatti L. Maternal perceptions of insufficient milk supply in breastfeeding. J Nurs Scholarsh 2008;40:355–363. 39. Hall H. Save Our Sleep: Helping Your Baby to Sleep Through the Night from Birth to Two Years. Vermillion, London, 2010. 40. Ford G. Contented Little Baby Book. NAL Trade, New York, 2001. 41. Boswell-Penc M, Boyer K. Expressing anxiety? Breast pump usage in American wage workplaces. Gender Place Culture 2007;14:551–567. 42. Galtry J. Suckling and silence in the USA: The costs and benefits of breastfeeding. Feminist Econ 1997;3:1–24.
Address correspondence to: Karleen D. Gribble, BRurSc, PhD School of Nursing and Midwifery University of Western Sydney Locked Bag 1797 Penrith, NSW 2751, Australia E-mail: [email protected]
‘‘I’m Happy to Be Able to Help:’’ Why Women Donate Milk to a Peer via Internet-Based Milk Sharing Networks Karleen D. Gribble
Abstract
The process by which women came to donate milk via online milk sharing networks was explored via a questionnaire administered to 97 peer milk donors. Seventy-one respondents stated that they were motivated to donate milk because they wanted to help someone. Many described milk donation as an empathic response to women with insufficient milk. Seventy-four respondents donated milk that they had previously expressed but did not need. Their desire to ensure that their milk was not wasted contributed to their decision to donate. Fiftyone respondents expressed milk specifically for donation, including 20 donors who initially donated previously expressed surplus milk but then expressed milk specifically for recipient peers. The motivations of peer-to-peer donors are the same as those reported for women donating to a milk bank. Respondents who donated previously expressed milk had originally expressed so they had milk when separated from their baby, to manage an overabundant milk supply, because their baby was unwilling or unable to breastfeed, in case of emergency, and to maintain milk supply. This study is the first to clearly identify that some women express milk because they believe this is required for milk supply maintenance. Peer milk donors appeared satisfied with their experience of donating milk. The importance of altruistic motivation should be considered in discussions of the desirability of financial compensation for milk donation. Further research is needed on why women express their milk and whether such expression is beneficial to them.
Introduction
P
eer-to-peer milk sharing involves the donation of expressed breastmilk by one woman to another woman for the purpose of feeding the second woman’s infant. Until recently such arrangements occurred sporadically because they required women with milk to share to have knowledge of the need of another for breastmilk. Because the sharing of breastmilk transgresses social norms and is often culturally unacceptable (e.g., Australia, New Zealand, and the United States), the dissemination of such knowledge was constrained.1–3 However, in 2011 social media was used to establish networks where individuals in need of milk and women with milk to share can advertise their desire to donate, or need for, milk. This has allowed the widespread facilitation of milk sharing between women previously unknown to one another. The gifting of milk by one mother to another mother’s infant is not a new phenomenon. Prior to the easy availability of refrigeration, such sharing was predominantly facilitated via wet nursing. Although wet nursing was often a paid oc-
cupation, unrenumerated wet nursing also occurred (e.g., Wolf 4). Since the beginning of the 20th century, sharing of expressed breastmilk via donor milk banks has provided human milk to sick infants. Although for much of the history of milk banks, donors received financial compensation, unpaid donations currently predominate.5 The current movement of peer-to-peer milk sharing shares characteristics of wet nursing and milk banking. In common with the former, the donation is a relationship-based action where individuals contract directly with one another. In common with the latter, it is expressed breastmilk that is shared. Descriptions of motivations for unpaid wet nursing are scant. Thorley6 described women with engorged breasts wetnursing infants whose mothers had insufficient milk or infants awaiting adoption, on the request of health providers. Krantz and Kupper,7 Fildes,8 and Shaw2 described friends breastfeeding each other’s infants for ‘‘mutual advantage’’ in sharing the work of infant care and allowing mothers to be involved in other activities. Finally, letters to the Nursing Mothers’ Association of Australia Newsletter described wet nursing between friends or relatives in sharing infant care,
School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia.
251
252
when a mother is unexpectedly absent or unable to breastfeed because of illness, and to assist in overcoming breastfeeding difficulties.9 Motivations for donating to milk banks have been the subject of research. Azema and Callahan10 found that women donated to a milk bank primarily because they had too much milk themselves and because they wished to help someone else. Pimenteira Thomaz et al.11 found that women decided to donate after it was suggested by a health professional, because they knew of the need for donor milk, and because they felt it was a social responsibility. Osbaldiston and Mingle12 found that women donated to help others because they had too much milk, knew that donations were needed, hoped that someone would do the same for them, and felt they needed to pump ‘‘to stimulate lactation.’’ The motivation and processes by which women donate expressed breastmilk to another woman has not previously been considered. This study sought to examine the motivation and processes by which women came to donate milk to a peer via the Internet. Materials and Methods
The study used a descriptive survey design containing closed and open-ended questions to examine the beliefs and practices of individuals involved in peer-to-peer milk sharing. A convenience sample of peer-to-peer milk donors and recipients was recruited via advertisement on the Facebook pages of the Internet-based milk sharing groups Human Milk 4 Human Babies and Eats on Feets. To be eligible to participate, individuals were required to have donated or received breastmilk in the previous 6 months in an arrangement that was facilitated via the Internet. Advertisements for the study directed individuals meeting the inclusion criteria to e-mail the study author. Individuals were e-mailed a letter outlining the method, background, and purpose of the study. Those who wished to participate were directed to request a copy of the study questionnaire, which contained 28 mostly open-ended questions. Ninety-one percent of peer milk donors who requested the study questionnaire returned a completed questionnaire. Ethics approval was obtained from the University of Western Sydney Human Research Ethics Committee. The results pertaining to reasons for donating milk to a peer are presented here. Respondents were asked questions about why they had donated milk to a peer and whether they donated previously expressed milk or had expressed milk specifically for donation. If they had previously expressed milk, they were asked why they had expressed this milk. They were also asked whether they would donate milk to a peer again. Closed-ended questions were analyzed using descriptive statistics, and conventional qualitative content analysis was used to analyze open-ended responses.13 Questionnaire responses were read, reread, and initially coded to reveal recurring themes. Codes that were conceptually similar were combined, as appropriate. Results
Ninety-seven milk donors from North America, Europe, Oceania, and Asia participated in the study. Donors ranged in age from 21 to 43 years, had from one to four children, and had previous breastfeeding experience of from 4 to 120
GRIBBLE
months. The child of the most recent lactation was from 0 to 17 months old. Donors had from one to nine recipients to whom they had donated 2–216 L. A summary of the characteristics of respondents is shown in Table 1. The reasons for donating milk were predominantly altruistic and practical. Altruistic motivation was the most prominent, as 73% of respondents stated they donated milk because they wanted to help someone: for example, ‘‘I’ve been very blessed with an ample milk supply and wanted to use this blessing to help another mama/baby.’’ Contributors to this altruistic motivation were evident in many responses. For some, prior experience with wet nursing, milk sharing, or insufficient milk had supported their decision to donate: for example, ‘‘I fully supplemented my baby sister for several months while my mother [was sick].. This sparked my interest in milk sharing’’ and ‘‘Some of my motivation stems from the fact that I had a very hard time nursing my first child. I didn’t even know that donor breastmilk was an option.’’ For others, hearing about an individual’s need was a catalyst: ‘‘I read an article about a mother who could not nurse because of health problems and her son was allergic to formula.. I couldn’t imagine having that happen and the feelings of helplessness. So I looked into donating.’’ As in the previous response, donors commonly placed themselves in the situation of women who were not able to fully breastfeed. Thus, their reasons for donating milk included an understanding that not everyone could make enough milk, an appreciation of how fortunate they were, and also how they would feel if they had insufficient milk: for example, ‘‘I’m extremely lucky that breastfeeding came easily to me.and that I have ample supply. I know that this is often not the case for others.. I figured that I had excess of what other people so desperately wished they had, so why not donate mine to them?’’ Respondents also stated that they would want someone to donate to them if they didn’t have enough: thus, ‘‘I just felt for mothers who wanted to breastfeed, but were unable for whatever reason.. If I were in that situation, I would want someone to help me out.’’ The practical motivation for women donating milk to a peer was evident in the 60% of respondents who stated they donated because they had excess milk production or unneeded expressed milk: for example, ‘‘I had so much excess milk [in the freezer] that I just knew I wouldn’t use’’ and ‘‘I had an excess of milk, due to oversupply, and I began expressing it and freezing it.’’ It was important to respondents with excess expressed milk that their milk not be wasted. As
Table 1. Characteristics of Donor Respondents Donors’ characteristics Age (years) Number of children Age (months) of child of most recent lactation Duration (months) of previous breastfeeding experience Number of recipients Volume (L) of milk donated
Mean
Standard deviation
30 (n = 97) 1.7 (n = 97) 3.2 (n = 93)
4.2 0.82 3.5
21 (n = 93)
18.0
2.1 (n = 97) 26 (n = 88)
1.7 39.4
WHY WOMEN DONATE MILK TO A PEER
253
stated by one respondent, ‘‘I was not about to throw that precious milk away.’’ Respondents also described how they donated their milk because they had an abundance of milk to give: ‘‘I had a very easy time producing breastmilk and wanted to help out.’’ A few respondents noted that donation to a milk bank was not possible, practical, or acceptable to them and also that they found milk expression easy. Many respondents expressed a belief that breastmilk is important or that infant formula is deficient: for example, ‘‘I think that breastmilk is an extremely important part of the growth and development of a child and every parent should have the option.to provide this to their infant.’’ Such beliefs supported both practical and altruistic motivations for donation. A summary of these results is shown in Table 2. The majority of respondents (76%) donated previously expressed surplus breastmilk: for example, ‘‘[I had] a very big freezer stash that needed to be used before it spoiled. I didn’t need it as my daughter had plenty of ‘fresh’ milk.’’ Others expressed specifically so that they could give the expressed milk to a peer: ‘‘I express milk to donate, and have worked to increase my supply so I can provide this to another baby.’’ Many women became involved in peer-to-peer milk sharing by donating surplus, previously expressed breastmilk and then continued to express milk specifically for donation. Of the 28 respondents who donated previously expressed breastmilk and expressed specifically for donation, 20 stated that they had started by donating their previously expressed milk but had then decided to express milk just to donate: for example, ‘‘Initially it was surplus
Table 2. Reasons for Donor Respondents Deciding to Donate Milk via Peer-to-Peer Milk Sharing Category of response Wanted to help a child/mother/family who needed milk Had expressed milk or excess milk that my child didn’t need Didn’t want expressed milk to go to waste Think breastmilk is important/view infant formula as deficient Made plenty of milk myself Was inspired by an individual’s story Know not everyone can make enough milk/feel luck to make enough milk/would feel terrible if I couldn’t make enough Would want someone to give me milk if I couldn’t make enough Previous experience with wet nursing/milk sharing Previous experience with insufficient milk Too difficult/not possible/didn’t want to donate to a milk bank Object to the costs charged by milk banks Find expressing easy
Frequency (n = 97) 71 59
Table 3. Type of Milk Donated by Donor Respondents Category of response Donated surplus expressed milk Expressed to donate Both surplus and milk expressed for donating
Frequency (n = 97) 74 51 28
[milk], then I pumped especially for the mother.’’ Results are shown in Table 3. The reasons why donor respondents had stored breastmilk to donate were explored. The most common reason by far was because they were physically separated from their infant while working: ‘‘[I expressed] so my son would have milk while I was at work.’’ It was also common to have expressed milk because of an oversupply of milk: ‘‘I have had an oversupply.. I began expressing my surplus of milk for comfort.’’ Many respondents expressed milk so that their baby could receive breastmilk if they were unexpectedly separated: ‘‘I wanted to have a small ‘‘emergency supply’’ in my freezer.’’ Some respondents felt that they needed to express to maintain their milk supply: ‘‘I express an extra feeding a day to keep up my milk supply.’’ Some respondents stated that they were exclusively expressing for their own baby who was unwilling or unable to breastfeed in the short or long term, or so that their baby could have their milk when they were away from them: for example, ‘‘Child is 100% tube fed, so I pump exclusively,’’ ‘‘My daughter had issues with latch for the first 3½ weeks of her life.. As a result, I was pumping,’’ and ‘‘[I expressed milk] to feed my son while I was out.’’ Less common reasons for expressing milk were so that the respondent’s partner could feed the baby, so that there was stored milk to feed the baby after breastfeeding had ceased, to mix with solid food, and as a mastitis treatment. A summary of results is shown in Table 4. When asked if they would donate milk to a peer again, 95 respondents stated that they would. Twenty noted that they were currently donating milk to a peer, one stated that she would also donate to a milk bank, and a further respondent
37 33 27 15 12
9 9 5 4 3 2
Table 4. Why Donor Respondents Had Previously Expressed Milk Category of response For while separated from baby because of work To deal with oversupply In case of emergency Maintain milk supply Baby unwilling or unable to breastfeed in the long term For when away from baby Baby unwilling or unable to breastfeed in the short term For partner to feed to baby To feed after breastfeeding had ceased Mix with solid food Treatment for mastitis
Frequency (n = 66) 29 14 9 7 6 5 5 3 2 1 1
254
stated that she would donate again but that she needed to keep track of milk kinship relationships. Two respondents stated that they might donate depending on the circumstances. Discussion
The desire to help another woman and her child motivated nearly three-quarters of peer milk donors. Donation via peer networks meets the definition of classical altruism in being a behavior that benefits an unrelated person while costing the individual performing the act.14 The actions of donors who donated partially because they hoped that someone would help them if they needed milk could be described as a type of reciprocal altruism.14 Donation as an empathic response was also evident in donors who described thinking processes where they had ‘‘put themselves in the shoes’’ of women who could not fully breastfeed.15 Although most respondents donated milk that they had previously expressed for other reasons, many expressed breastmilk specifically for donation. It was the circumstances of women who had insufficient milk that motivated expression and donation of milk. However, more than a quarter of women who had initially engaged in milk sharing by donating their surplus expressed breastmilk continued to express milk specifically for donation. Respondents stated that it was the circumstances of the recipient and knowing her and her child that motivated them to continue donating. As identified previously, the specific knowledge of the need for milk can make additional expressed breastmilk available.16 Good feelings after donation may have also encouraged women to express additional milk for donation. Other research has identified that giving to help others increases donors’ feelings of well-being and contributes to continued donation.17,18 This response has been identified in blood donation and may also apply in milk donation.18 It has been argued that donations providing this ‘‘feel good’’ reaction should be considered as benevolence rather than pure altruism.18 Regardless, that donors can produce additional milk in response to the context of donation suggests that breastmilk can be viewed as a renewable, rather than a limited, resource. More than half of respondents donated expressed breastmilk that their infant did not require, and most did so because they did not want milk to be wasted. As noted elsewhere, peer-to-peer milk donors highly value their milk. This value is derived from the work of expressing milk, understanding of the importance of breastmilk and their view of breastmilk as a part of themselves.16 Peer-to-peer milk sharing enabled meaningful use of their breastmilk. In describing the ideal human milk bank donor, Arnold and Borman19 nominate, as characteristic, (1) a desire to help another infant or child and (2) an unwillingness to waste expressed milk. One or both of these motivations underlaid why donor respondents donated their milk. It has been identified that peer-to-peer milk donors differ in important ways from milk bank donors in terms of eligibility, philosophy of milk donation, and the need to know recipients’ circumstances.16 However, they do not appear to differ in terms of motivation to donate. All reasons for donation reported by respondents had previously been reported as motivating milk bank donors.10–12 Peer-to-peer milk donors also show a similarly high level of satisfaction with donating as milk bank donors.12
GRIBBLE
The motivations underlying donation of human tissues, such as blood, are recognized as influencing the safety of the donation.20 Research has revealed that altruistic blood donation provides the highest level of safety.21 It has been proposed that in order to increase donation to milk banks, milk donors should be paid.22 Payment for milk may undermine the altruistic motivation of donation and decrease the quality and volume of donations. Recent research has identified that purchased human milk has high levels of bacterial contamination.23,24 Before a decision is made to pay women for milk bank donations, the experiences of blood banks with payment of donors should be considered. That many respondents had excess expressed milk to donate is of interest. The expression of breastmilk is increasingly common. For example, in the United States, the Infant Feeding Practices II Study found that 85% of breastfeeding women had expressed breastmilk.25 In Perth, Australia, the proportion of mothers expressing breastmilk increased from 38% to 69% between 1993 and 2003.26 The increasing incidence of milk expression has been linked to the easy availability of breast pumps, questionable marketing of pump manufacturers, and increased participation of women in the waged workforce.27,28 In many countries, breast pumps are now considered to be a ‘‘necessity’’ of modern motherhood.27 For example, in the United States, health insurers are required by law to provide new mothers with a breast pump.27,29 However, the degree to which the ubiquity of breast pumps assists or hampers breastfeeding women has yet to be ascertained.30 The reasons given by respondents for expressing milk have largely been identified in the general population of women who express milk. For example, maternal employment, overproduction of milk, in case of an emergency, because an infant is unable or unwilling to breastfeed, for when separated from the baby, for someone else to feed the baby, and to mix with solid food have all previously been identified as reasons for milk expression.31–34 Expressing milk in order to maintain a milk supply has not been clearly identified previously. This is perhaps because studies of milk expression have provided a checklist of reasons for milk expression rather than allowing women to use their own words to describe why they had expressed milk. However, there is some evidence suggesting that women expressing milk to maintain a milk supply is not anomalous. Osbaldiston and Mingle12 found that a percentage of milk bank donors indicated in a checklist that they expressed milk ‘‘to stimulate lactation.’’ The meaning of this phrase is unclear. It could describe women with low milk supply expressing to increase milk production. However, this group of women were high-volume donors, suggesting that they were expressing milk in excess of requirements. Similarly, Geraghty et al.,35 in a study of breastfeeding practice, found that some women ‘‘overproduced’’ via milk expression. Thus, it seems that it may be common for women with sufficient milk to express to excess. Milk production is a supply and demand process, and in the absence of physiological abnormalities, breasts will make the milk required in response to milk removal by the baby.36 However, women commonly believe that they do not make enough milk (e.g., Hillervik-Lindquist37), which often leads to cessation of breastfeeding or introduction of infant formula.38 Expressing milk ‘‘to maintain milk supply’’ may be a new response to perceived insufficient milk. The belief that
WHY WOMEN DONATE MILK TO A PEER
expressing milk is necessary may flow from baby books that include expressing sessions in their ‘‘breastfeeding schedules.’’39,40 Finally, the use of breast pumps in situations for which a clinical indication is lacking is concerning.31 Although an increase in the production and expression of milk is a boon to milk banks and individuals in need of milk for their infant, this trend should not be considered unquestioningly good. Previous research has identified that mothers commonly use expression to help them overcome problems with breastfeeding.26 However, there is some question as to whether this is always beneficial. For example, women may eschew breastfeeding and pump and bottle feed their milk because they are experiencing nipple pain.32 Milk expression may be easier than obtaining skilled breastfeeding assistance, but ultimately not provide a solution and result in early weaning. Similarly, the expectation that women can combine breastfeeding and work via milk expression may undermine other solutions such as paid maternity leave or onsite childcare.41,42 Finally, although Osbaldiston and Mingle12 suggested that women who are expressing to ‘‘stimulate their milk supply’’ should be actively targeted for recruitment as milk donors, it is questionable whether this is appropriate. Rather, such women may benefit from support and assistance concerning their likely ability to breastfeed without the need for additional expression. Conclusions
In common with milk bank donors, peer-to-peer milk donors donate their milk primarily because they want to help and because they do not want their expressed milk to be wasted. Such motivations are protective factors for those seeking milk from a peer. Individuals considering the purchase of breastmilk should consider how the motivation of milk sellers might vary from that of milk donors and how this might impact milk quality. Further research into milk expression is needed to better understand whether milk expression is occurring unnecessarily or to the detriment of mothers and infants. Acknowledgments
The author thanks the women who so kindly shared their experiences and the administrators of the Human Milk 4 Human Babies and Eats on Feets Facebook pages who assisted with participant recruitment. References
1. Thorley V. Mothers’ experiences of sharing breastfeeding or breastmilk co-feeding in Australia 1978–2008. Breastfeed Rev 2009;17:9–18. 2. Shaw R. Virtues of cross-nursing and the ’yuk factor.’ Aust Feminist Stud 2004;19:287–299. 3. Bar-Yam NB. Sharing breastfeeding: The experience of cross nursing among mothers in the United States. Birth Issues 2005;14:57–63. 4. Wolf JH. ‘‘Mercenary hirelings’’ or ‘‘a great blessing’’?: Doctors’ and mothers’ conflicted perceptions of wet nurses and the ramifications for infant feeding in Chicago, 1871– 1961. J Soc History 1999;33:97. 5. Golden J. From commodity to gift: Gender, class and the meaning of breastmilk in the 20th-century. Historian 1996;59:75–87.
255
6. Thorley V. Human milk use in Australian hospitals, 1949– 1985. Breastfeed Rev 2012;20:13–23. 7. Krantz JZ, Kupper NS. Cross-nursing: Wet-nursing in a contemporary context. Pediatrics 1981;67:715–717. 8. Fildes V. Wet Nursing: A History from Antiquity to the Present. Blackwell Publishers, Oxford, United Kingdom, 1988. 9. Michael M, Faraj J, Wlicox K, et al. Wet nursing. Nurs Mothers Assoc Aust 1994;30:13–18. 10. Azema E, Callahan S. Breast milk donors in France: A portrait of the typical donor and the utility of milk banking in the French breastfeeding context. J Hum Lact 2003;19:199–202. 11. Pimenteira Thomaz AC, Maia Loureiro LV, da Silva Oliveira T, et al. The human milk donation experience: Motives, influencing factors, and regular donation. J Hum Lact 2008;24:69–76. 12. Osbaldiston R, Mingle LA. Characterization of human milk donors. J Hum Lact 2007;23:350–357. 13. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277–1288. 14. Fehr E, Fischbacher U. The nature of human altruism. Nature 2003;425:785–791. 15. Hein G, Singer T. I feel how you feel but not always: The empathic brain and its modulation. Curr Opin Neurobiol 2008;18:153–158. 16. Gribble K. Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks. J Obstet Gynecol Neonatal Nurs 2013;42:451–461. 17. Anik L, Aknin LB, Norton MI, et al. Feeling good about giving: The benefits (and costs) of self-interested charitable behavior. Harvard Business School Market Work Paper 2009;No. 10-012. 18. Ferguson E, Farrell K, Lawrence C. Blood donation is an act of benevolence rather than altruism. Health Psychol 2008;27:327–336. 19. Arnold LDW, Borman LL. What are the characteristics of the ideal human milk donor? J Hum Lact 1996;12:143–145. 20. Titmuss RM. The Gift Relationship: From Human Blood to Social Policy. New Press, New York, 1997. 21. Wylie B. Which methods of donor recruitment give the safest donors? Malay J Pathol 1993;15:99–103. 22. Medo ET. Increasing the global supply and affordability of donor milk. Breastfeed Med 2013;8:438–441. 23. Keim SA, Hogan JS, McNamara KA, et al. Microbial contamination of human milk purchased via the Internet. Pediatrics 2013;132:e1227–e1235. 24. Geraghty SR, McNamara KA, Dillon CE, et al. Buying human milk via the Internet: Just a click away. Breastfeed Med 2013;8:474–478. 25. Labiner-Wolfe J, Fein SB, Shealy KR, Wang C. Prevalence of breast milk expression and associated factors. Pediatrics 2008;122(Suppl 2): S63–S68. 26. Binns CW, Win NN, Zhao Y, et al. Trends in the expression of breastmilk 1993–2003. Breastfeed Rev 2006;14:5–9. 27. Martucci J. Breast pumping. Virtual Mentor 2013;15:791– 797. 28. Van Esterik P. Expressing ourselves: Breast pumps. J Hum Lact 1996;12:273–274. 29. Drago R, Hayes J, Yi Y. Better Health for Mothers and Children: Breastfeeding Accommodations Under the Affordable Care Act. Institute for Women’s Policy Research, Washington, DC, 2010. 30. Rasmussen KM, Geraghty SR. The quiet revolution: Breastfeeding transformed with the use of breast pumps. Am J Public Health 2011;101:1356–1359.
256
31. Clemons SN, Amir LH. Breastfeeding women’s experience of expressing: A descriptive study. J Hum Lact 2010;26: 258–265. 32. Johnson S, Leeming D, Williamson I, Lyttle S. Maintaining the ’good maternal body’: Expressing milk as a way of negotiating the demands and dilemmas of early infant feeding. J Adv Nurs 2012;69:590–599. 33. Sisk P, Quandt S, Parson N, et al. Breast milk expression and maintenance in mothers of very low birth weight infants: Supports and barriers. J Hum Lact 2010;26: 368–375. 34. Labiner-Wolfe J, Fein SB, Shealy KR, et al. Prevalence of breast milk expression and associated factors. Pediatrics 2008;122(Suppl 2):S63–S68. 35. Geraghty SR, Sucharew H, Rasmussen KM. Trends in breastfeeding: It is not only at the breast anymore. Matern Child Nutr 2013;9:180–187. 36. Kent JC. How breastfeeding works. J Midwifery Womens Health 2007;52:564–570. 37. Hillervik-Lindquist C. Studies on perceived breast milk insufficiency. A prospective study in a group of Swedish women. Acta Paediatr Scand Suppl 1991;376:1–27.
GRIBBLE
38. Gatti L. Maternal perceptions of insufficient milk supply in breastfeeding. J Nurs Scholarsh 2008;40:355–363. 39. Hall H. Save Our Sleep: Helping Your Baby to Sleep Through the Night from Birth to Two Years. Vermillion, London, 2010. 40. Ford G. Contented Little Baby Book. NAL Trade, New York, 2001. 41. Boswell-Penc M, Boyer K. Expressing anxiety? Breast pump usage in American wage workplaces. Gender Place Culture 2007;14:551–567. 42. Galtry J. Suckling and silence in the USA: The costs and benefits of breastfeeding. Feminist Econ 1997;3:1–24.
Address correspondence to: Karleen D. Gribble, BRurSc, PhD School of Nursing and Midwifery University of Western Sydney Locked Bag 1797 Penrith, NSW 2751, Australia E-mail: [email protected]
