Breast milk donation and social support: reports of women donors

Abstracts

O estudo objetivou caracterizar o comportamento de doação de leite humano e descrever o apoio social informal e institucional, segundo relatos de mulheres doadoras. Trata-se de estudo exploratório, descritivo, de corte transversal, com entrevista domiciliar baseada em roteiros estruturado e semiestruturado. Participaram 36 mulheres cadastradas em dois bancos de leite humano da rede pública de saúde do Distrito Federal. Foram realizadas análises estatísticas descritivas de dados quantitativos e categorial de conteúdo dos dados qualitativos. Categorias de motivos que mais influenciaram na frequência da ordenha: alimentação, disponibilidade de tempo, emoções negativas e ingestão de líquidos. A ordenha manual foi referida como técnica predominante. O uso da “conchinha” foi citado por quase um terço das doadoras. Sugestões mais frequentes para melhorar o apoio institucional foram maior atenção e apoio dos bancos de leite às doadoras. O estudo poderá servir de estímulo para implementação de estratégias técnicas e políticas que favoreçam essa prática.

Apoio Social; Leite Humano; Bancos de Leite; Gênero e Saúde

El estudio objetivó caracterizar el comportamiento envuelto en la donación de leche humana y describir el apoyo social informal e institucional, según relatos de mujeres donadoras. Se trata de un estudio exploratorio, descriptivo, de corte transversal, con entrevista domiciliar basada en guiones estructurados y semiestructurados. Participaron 36 mujeres registradas en dos bancos de leche humana de la red pública de salud del Distrito Federal. Fue realizado el análisis estadístico descriptivo de los datos cuantitativos, y el categórico de contenido de los datos cualitativos. Las categorías de motivos que más influyeron en la frecuencia de la extracción de leche: alimentación, disponibilidad de tiempo, emociones negativas e ingestión de líquidos. La extracción de leche manual fue referida como técnica predominante. El uso de la “conchita” fue citado por casi un tercio de las donadoras. Sugerencias más frecuentes para mejorar el apoyo institucional fueron mayor atención y apoyo de los bancos de leche a las donadoras. El estudio podrá servir de estímulo para implementación de estrategias técnicas y políticas que favorezcan esa práctica.

Apoyo Social; Leche Humana; Bancos de Leche; Género y Salud

ORIGINAL ARTICLE

Breast milk donation and social support: reports of women donors¹

Lucienne Christine Estevez de Alencar^I; Eliane Maria Fleury Seidl^II

Instituto de Psicologia, Universidade de Brasília, DF, Brazil:

^INutritionist, M.Sc. in Psychology. E-mail: [e-mail]

^IIPsychologist, Ph.D. in Psychology, Faculty. E-mail: [e-mail]

^{Corresponding Author}

ABSTRACT

The study aimed to characterize the behavior of human milk donation and to describe the informal social and formal institutional support, according to reports from women donors. It is an exploratory, cross-sectional, descriptive study using domicile interviews based on structured and semi-structured scripts. The participants were 36 women enrolled in two human milk banks of the public health system of the Federal District. Statistical analysis of quantitative data and categorical content analysis of qualitative data were performed. Categories of reasons that most influenced the frequency of expressing were: food, time availability, negative emotions and fluid intake. The manual expressing technique was reported as predominant. The use of breast shells was cited by almost a third of the donors. Most frequent suggestions for improving institutional support were more attention and support from the milk banks for the donor. The study may serve as a stimulus for the implementation of technical and political strategies to encourage this practice.

Descriptors: Social Support; Milk, Human; Milk Banks; Gender and Health.

Introduction

In recent decades, the concept of social support has been the study target of several Brazilian and foreign researchers in the field of health^(1-2). An initial definition of the concept of social support indicates that it is “information that leads individuals to believe that they are cared for, loved, esteemed and that they belongs to a social network with mutual obligations”⁽²⁾.

Studies of social support focus the perception concerning the availability and the type of support received, also covering the satisfaction with it. Two categories of support have prevailed in the literature: instrumental and emotional. The first category refers to the availability of help to assist the person in the management or resolution of practical situations or quotidian operation, with material or financial support or various day to day activities. Emotional support consists of behavior such as listening, providing attention or keeping company which contribute to the person feeling cared for and/or esteemed⁽¹⁾.

Another interesting aspect concerns the sources of social support. These may be informal (family, friends, people of religious groups) and formal (institutional, professional), however, they can also act in a complementary way. Therefore, it is necessary to consider these aspects in studies that investigate the types of support received by people in the different contexts of health, illness and vulnerability.

The concept of social support interfaces with that of the social network, which has also guided studies in the area of health. As an example, researchers have created social network maps of breastfeeding women⁽³⁾. The results indicated the presence of strong bonds between these women and people of the primary network such as friends, neighbors, their mother, or the father of the child, being those most involved with the mothers in the breastfeeding process. The authors concluded that the methodological framework of the social network can facilitate a comprehensive approach towards this theme in studies and professional interventions.

A question emerged in this study: how to structure, both formally and informally, social support for women donating breast milk? How does the woman perceive this support? Initially, it is important to note that the woman donor is in a time of life that may include adaptive aspects, possibly with stressful features: the recent experience of maternity; caring for the baby, often their first child; the donation being a continuous act over a period of time unlike blood donation which takes place in a single episode^(4-5).

Another issue relates to the fact that the practice of milk donation is consolidated from actions involving public institutions - the Human Milk Bank (HMB), the Fire Department (FD) -, implying regular relationships: contacts at home for collection and provision of necessary equipment such as jars for storage, masks and caps. From this perspective, HMBs have, in recent years, been made strategic elements in relation to the promotion and encouragement of breastfeeding and the donation of human milk, as well as representing driving centers of state policy, undergoing a series of ideological changes in their institutional practice, since the first unit deployed in the country in 1943⁽⁶⁾. Thus, it is clear that social support for the woman donor is related to public health policies, including HMB and the FD, as well as their families and individuals in their social bond. However, it has peculiarities that are not well understood, such as the perception of these women about the support received by these social actors^(7-8).

This study aimed to characterize the behavior of donation and to describe the informal social and formal institutional support, identifying the level of satisfaction with the support received, according to reports from women donors enrolled at two milk banks in the public health system of the Federal District.

Methods

This work is part of a larger study conducted by the first author⁽⁹⁾, under the guidance of the second author, which aimed to identify the motives, beliefs and feelings related to the practice of donation, from reports of women donors, and was conducted between May 2005 and November 2006⁽⁸⁾.

The project was first submitted to the Research Ethics Committee of the Health Secretariat of the Federal District. Upon approval, a pilot study was conducted with the aim of evaluating the adequacy of the interview script prepared for the research and data collection procedure proposed (interview in the domicile). Interviews were conducted on the basis of structured and semi-structured scripts, prepared for the study, containing questions relevant to the research objectives. The participants were 36 women enrolled in two HMBs of the public health system of the Federal District. The number of women represented 20.2% of the total 178 donors of the HMBs included in the study. Twenty seven women were current donors and nine recent former donors, based on the established criteria.

The descriptive statistical analysis of quantitative data included measures of frequency, dispersion and central tendency, using the software Statistical Package for Social Sciences (SPSS) version 13.0. Regarding the analysis of the qualitative data, analytical procedures for categorical content were used⁽¹⁰⁾.

The interviews were first transcribed in their entirety. Next, the open questions of all participants were read horizontally. The verbal reports were analyzed and categorized, based on their content by two independent researchers (the researcher and supervisor), seeking agreement of not less than 70% for the identification, naming and frequency of the categories. Excerpts from the reports of the participants in the study were selected as examples of the categories.

Results

The age range of participants was between 14 and 33 years (m=24.78; sd=5.22). A key issue dealt with the frequency of extraction of milk by women participants, known by the technical name ‘expressing’. It was observed that the majority (n=26; 72.2%) of the women expressed their milk more than once a day, 8.3% (n=3) reported expressing once a day and 19.4% (n=7) reported that the frequency was variable.

As to how breast milk was being expressed by the participants, it was observed that the technique of expressing manually prevailed over others (n=22; 61.1%), which meets the technical standards for human milk banks⁽¹¹⁾. However, almost one third (n=11; 30.5%) reported the use of breast shells, which has not been recommended due to the possibility of negative consequences as regards the risk of microbiological contamination of the expressed milk. The use of the manual or electric pump was reported for the remainder of participants (n=3; 8.4%). When asked if any factor interferes with expressing frequency, 83.3% (n=30) of respondents answered yes, some of them referring to more than one factor affecting this. Strictly speaking, this frequency was related to milk production. Table 1 shows the factors related to the frequency of expressing in categories, along with the classification of the influences as positive or negative on the aspects mentioned. From the reports, the consideration as to which factors could facilitate or prejudice milk production was made.

Regarding the frequency with which the HMBs would collect the milk from the domiciles of the women interviewed, 25 (69.4%) of them reported that this occurred weekly and 11 (30.6%) reported a fortnightly frequency. It is important to realize that, the frequency of HMB collection depends on the organizational aspects of the institution, such as the availability of transport and human resources for this task. When questioned about whether they knew what was happening with their milk, after donating it to the HMB, 16 (44.4%) of them reported that they did not know about the procedures performed, 12 (33.3%) were poorly informed and eight (22.2%) adequately informed, based on their reports. With regard to receiving information about the donation of human milk before the baby was born, 16 (44.4%) reported that they had received nothing. Nine of them (25%) mentioned that this occurred during the prenatal period and six (16.7%) received information during previous pregnancies. On the occurrence of doubts at the beginning of the process of donation, the majority (n=24; 66.7%) reported hygienic and sanitary procedures required in the expressing process, such as carrying out the expressing, how to sterilize the materials to store the milk at home, how long the milk could stay in the shell, how to store the milk, where to put the milk after expressing, use of mask and cap, why the baby can not suckle on another woman donor.

When questioned about the presence of doubts about donation at the time of the survey, 29 (80.6%) women responded that they did not have any, and seven (19.4%) of them admitted that they still had doubts about donating, which are categorized in Table 2.

When asked about the support received from people in their family environment regarding the act of donation, 32 women (88.9%) responded affirmatively. From the descriptions of the types of support received, the reports were categorized. Table 3 presents the categories, their frequency and examples that relate behavior considered by interviewees as support for donation.

When invited to describe the support received from the institutions involved in the donation process (HMB and/or FD), 36.4% (n=12) of respondents answered that they did not feel supported by either of these services. Conversely, 30.3% (n=10) reported having received support from HMB and 21.2% (n=7) from the FD and HMB. Regarding the satisfaction of participants with the support received by people in their social life and by the institutions responsible, 91.7% (n=33) and 58.3% (n=21) reported being satisfied, respectively. In relation to institutional support, ten women (27.8%) reported dissatisfaction and five (13.9%) reported being partially satisfied. The following reports illustrate the satisfaction with the institutional support received;

I think the girls who come to pick up the milk ... give support, they seem to be close to us ... every time they come they ask how I am, (..) the question of quarantine (...) I can’t leave the house much and so whenever they came they would ask how I was doing and if I was okay and they would give some tips, their support was very gratifying (D8).

One report illustrates the partial level of satisfaction.

I think they should have more support... more incentive... for people to donate... there are many people who don’t have any initiative to donate, so I think if they could be encouraged more... for us to donate, to look for some way, I do not know how, to encourage more people, sometimes people can donate, they want to donate but they don’t know how, there is very little information and they end up not donating (D22).

Concerning dissatisfaction with institutional support, the following report is illustrative.

No, I do not consider as a support no, I think they have their interests that are in the milk but to support us, they do not support, in my opinion. I am satisfied with the milk donation, but not with their support (D11).

The participants were unanimous in reporting that they had not received a visit from a BLH worker from where they were donors or are donating their milk, in addition to the visits to collect milk stored by donors. To improve the support of the HMBs and FD for women donors, the participants made a series of suggestions, when instigated by the researcher, categorized in Table 4.

Faced with the question requesting an evaluation of the experience of donating, 33 participants (91.7%) said that it was positive. Of the 27 participants who were donating milk, 18 (66.7%) stated that they intended to continue donating while they had an excess of milk.

Discussion

One of the main purposes of this study was to achieve some understanding of the theme of human milk donation, from reports of women donors. Therefore, we included two HMBs considered coverage centers in the region, one of which stood out as a reference in the Federal District.

It can be hypothesized that many potential donors have their intentions frustrated, not being able to put into practice their role as a donor. It is pertinent to suggest that the routine of collection and the relationship between HMBs-donor are being rethought in the light of issues raised by participants. Despite the reports of satisfaction with the institutional support received, suggestions made by them speak of the need to enhance technical support, to receive and to monitor the donors⁽¹²⁾, particularly with regard to educational aspects and attention to the woman which may even increase the time of donation and quality of milk collected. In this sense, the use of breast shells emerges - a method that seems to favor the process of expressing - but that has not been recommended according to technical standards⁽¹¹⁾.

The process of taking the decision to donate can be influenced by the kind of assistance received, whether it is humanized or not, and the valorization of autonomy, highlighting that adequate communication has a fundamental effect on this process. Another important point, mentioned earlier, that deserves to be discussed in the present study is the method of expressing. It is preferable that the collection of human milk is made by hand expressing manually, an electric or manual pump may also be used, because the quality of human milk collected, that is to be pasteurized, directly depends on the hygienic and sanitary procedures applied during the expressing⁽¹¹⁾.

In the group of women who reported expressing more than once a day, the method of manual expressing was prevalent, however, half the participants in this group reported using the breast shell to extract their milk. Focusing on the total sample, almost one third of participants said that they make use of the breast shell. This type of method makes the situation worrisome, because the preference for this object is related, according to the interviewees, to practicality, comfort and time saving, eliminating the use of the cap and mask. This characterizes a probable lack of information about the proper procedures recommended in the scientific literature⁽¹¹⁾.

It can be suggested, as an educational measure, that information is provided to the donor by the formal support network on the risks that may cause contamination of raw, expressed human milk, especially when collected in breast shells. This could contribute significantly to avoid unnecessary expenses for the HMBs because efforts are undertaken in the course of the stages through which human milk passes before being consumed. It is important that the HMBs receive financial input, as well as human resources, in order to provide time to attend to the demands of the donors. It is suggested that preventive actions are implemented, through continuous monitoring of these women, at least at the time the HMBs makes the first domicile collection.

As for factors that interfere with milk production, it was noted that the aspects most cited by donors, such as fluid intake, type of diet, presence of negative emotions, frequency of expressing and suckling of the baby, are mentioned in the literature^(7,13) as factors influencing the increase or decrease in milk production, indicating agreement between these responses and the scientific evidence. However, contraceptive use, the mother going out and the return to labor activity could be considered subjective variants that every woman faces in her everyday life. Situations such as lack of available time, physical exhaustion and laziness to express milk are those cited categories that deserve to be further studied, since expressing manually demands a lot of care that takes time and, depending on the tasks of the volunteers, may limit the practice of donation. This explains the fact that many women included in this study stated that they could donate their milk more often, but did not. From this perspective, educational activities could be implemented by HMBs, first, listening to the mothers and then educating them about the difficulties, offering support and guidance for coping with them. This might contribute to closer bonds between the HMBs and the donors, and perhaps reduce the difficulties of the mothers and contribute to increase the frequency of expressing⁽¹³⁾.

The precariousness of information for the donor on the processing and fate of the milk donated to the HMB is evident. As a result, it is suggested that, through educational work by the HMBs with the donors of human milk, the treatment given to raw human milk and the main destinations that will receive the pasteurized milk, are explained. To make discussions with women during the prenatal period, to invite them to visit the HMB while still pregnant, to take them to visit the maternity ward, to show them who the consumers of donated human milk are, and to invite them to observe, at the location, the steps that the raw, donated human milk passes through up to the moment it is consumed, are some suggestions proposed by the women interviewed and could be implemented by the HMBs.

It is believed that the first visit by HMB professionals to the donor’s domicile is important to clarify any possible doubts that the donor may have. To offer humanized support, to explain how to identify excess milk, or to suggest that they make a visit to the HMB to be examined by a technically skilled professional can serve as elements that contribute to reduce difficulties, doubts and waivers in the act of donation^(4,7). It is considered that the performance of visits by the HMB workers, outside the days on which collections are made, could ease the doubts arising from the practice of donation and ensure that the donated human milk meets the requirements determined by the technical standards. However, for this to occur, it is important that the HMBs receive technical and political support, prioritizing financial and human resources so that these suggestions can be put into practice.

Conclusion

Considering the results, it was conclude that humanized institutional care, permeated by the actions of encouragement and improvements in the communication process about donation⁽¹²⁾, associated with social support from people significant to the donor, could help to strengthen the human milk donation network, facilitating the loyalty of these volunteers should they become pregnant again. Another possibility is that these donors engage in the role of multiplier within their social relationships, disseminating information and values that promote the engagement of new women donors.

Moreover, the improvement of institutional/organizational processes and the training of human resources engaged in this area may increase the quality of the network of milk banks and partner organizations, aiming to improve the responses of these institutions to the demands of interested people, especially women human milk donors.

Received: Jun. 7^th 2009

Accepted: Mar. 3^rd 2010

• 1. Seidl EMF, Tróccoli BT . Desenvolvimento de escala para avaliaçăo do suporte social em HIV/Aids. Psicol Teor Pesq. 2006; 22(3):317-26.
• 2. Cobb S. Social support as a moderator of life stress. Psychosom Med. 1976; 38(5):300-14.
• 3. Souza MHN, Souza IEO, Tocantins FR. The use of social network methodological framework in nursing care to breastfeeding women. Rev. Latino-Am. Enfermagem. 2009; 17(3):354-60.
• 4. Moura AS, Moreira CT, Machado CA, Vasconcelos Neto JAV, Machado Mde FAS. Doador de sangue habitual e fidelizado: fatores motivacionais de adesăo ao programa. RBPS. 2006; 19(2):61-7.
• 5. Haslam SA, OBrien A, Jetten J, Vormedal K, Penna, S. Taking the strain: social identity, social support, and the experience of stress. BJSP. 2005; 44:355-70.
• 6. Almeida JAG. Amamentaçăo: um híbrido natureza-cultura. Rio de Janeiro: FIOCRUZ; 1999. 119 p.
• 7. 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(2):199-202.
• 8. Alencar LCE de, Seidl EMF. Doaçăo de leite humano: experięncia de mulheres doadoras. Rev Saúde Pública. 2009; 43:70-7.
• 9. Alencar LCE de. Doaçăo de leite humano no Distrito Federal: aspectos psicossociais e experięncias de mulheres doadoras [dissertaçăo mestrado]. Brasília (DF): Instituto de Psicologia da Universidade de Brasília; 2006. 102 p.
• 10. Bauer MW, Gaskell G. Pesquisa qualitativa com texto, imagem e som: um manual prático. Săo Paulo:Vozes; 2002. 516 p.
• ¹¹
  Normas técnicas para bancos de leite humano. Ordenha: procedimentos higiênico-sanitários. 2004. [acesso em: 08 outubro 2006]. Disponível em: http://www.redeblh.fiocruz.br/media/coleta.pdf
• 12. Silva MJP. O papel da comunicaçăo na humanizaçăo da atençăo ŕ saúde. Bioética. 2002; 10(2):73-88.
• 13. Albernaz E, Victora CG. Impacto do aconselhamento face a face sobre a duraçăo do aleitamento exclusivo: um estudo de revisăo. Rev Panam Salud Publica. 2003; 14(1):17-24.

1

Paper extracted from Master’s Thesis "Doação de leite humano no Distrito Federal: aspectos psicossociais e experiências de mulheres doadoras" presented to Instituto de Psicologia, Universidade de Brasília, DF, Brazil.

Publication Dates

• Publication in this collection
  11 Aug 2010
• Date of issue
  June 2010

History

• Received
  07 June 2009
• Accepted
  03 Mar 2010