Human milk should be the primary source of nutrition for preterm infants, as mother’s own milk (MOM) contains many nutrients and bioactive components associated with improved preterm health outcomes [1]. Additionally, preterm MOM contains higher concentrations of proteins, growth factors, and metabolic hormones, specifically in colostrum, compared to mature MOM [1, 2]. However, mothers of preterm babies can face biological barriers to milk production due to inadequate mammary development as a result of early delivery [3].
In the case that MOM is not available or is contraindicated due to maternal illness [4] or medications [5], the American Academy of Pediatrics (AAP) recommends feeding the infant pasteurized donor human milk (DHM) [6]. Despite the well-documented health benefits of human milk for very low birth weight (VLBW) infants, including decreased risk of necrotizing enterocolitis [7], bronchopulmonary dysplasia [8], urinary tract infections [9], and sepsis [10]−[11], many VLBW infants are not being fed human milk as measured at discharge from the NICU hospitalization [12]. DHM, usually obtained from term mothers and received by preterm infants, may contain different bioactive and nutritional properties compared to MOM due to factors including shelf life, processing, storage in a freezer, mammary gland maturity, and stage of lactation [2, 13]. However, when MOM is unavailable, DHM is the next best alternative for preterm infants [14]. Research from California (CA) hospitals demonstrated that access to DHM is associated with a 10% increase in breastfeeding rates [15]. Additionally, it has been found that DHM access is not associated with decrease in MOM provision during the infant’s hospitalization [16].
Yet racial and ethnic gaps in rates of both MOM and DHM feedings exist. Black VLBW infants receive less MOM compared to non-Black VLBW infants [1]. Similarly, DHM use is lower among infants born to Black and Hispanic mothers compared to infants born to non-Hispanic White mothers [17]. Much of the current literature examines human milk inequities at the time of discharge [18, 19]; however, not much is known about inequities that may exist around access to DHM at the hospital level. In order to gain access to DHM, California hospitals need to be licensed in handling, storing, and preparing DHM, following similar guidelines to other human tissue banking [20]. Due to the need for a milk bank supplier, increased costs for personnel training, and DHM product maintenance, some hospitals choose not to acquire DHM licensure despite the potential for cost savings by reducing NEC rates [21]. DHM provided by milk banks are often not reimbursed by health insurance companies [22]. Since hospitals would need to find a source of funding or cover these costs themselves, they may be less inclined to offer DHM to their patients. Hospitals that are more likely to have access to DHM include Level 3 and Level 4 facilities and those that are designated as ‘Baby Friendly’ [23]. At the national level, safety net hospitals, which serve a higher percentage of patients with Medicaid, are less likely to have access to DHM [24, 25]. Both the United States Surgeon General and the American Academy of Pediatrics have called for improvements in equitable access to and the affordability of DHM [26, 27]
We examined access to DHM at the hospital level among California NICUs to evaluate whether equitable access exists along racial, ethnic, or insurance lines. Our aim was to understand potential drivers of decreased overall human milk use among marginalized populations, specifically DHM, with the broader goal of decreasing health disparities among NICU infants. Throughout this paper, the authors often use the term MOM as this was the term most commonly used in the literature referenced. The authors recognize that not every lactating person refers to themselves as “mother” and hope to build a more inclusive body of research that celebrates patient- centered care for all bodies.