In total, 44 individuals participated in five FGDs including two with mothers, one with fathers, and two with CHWs. In addition, nine key informant interviews were conducted. Summary characteristics of FGDs and KIIs are shown in Tables 1 and 2. The primary themes identified related to donor breast milk were awareness and knowledge of breast milk sharing (Theme 1); rationales for engaging in breast milk sharing (Theme 2); and hesitancies about breast milk sharing (Theme 3).
Table 1
Focus Group Discussion (FGD) Participants
| Group name | Number of participants (mean age and SD in years) |
| Mothers, Group 1 | 8 (23.1 ± 2.4) |
| Mothers, Group 2 | 7 (24.6 ± 5.5) |
| Fathers | 9 (28.3 ± 4.3) |
| Community Health Workers, Group 1 | 10 (33.1 ± 10.6) |
| Community Health Workers, Group 2 | 10 (31.6 ± 5.1) |
Table 2
Key Informant Interview (KII) Participants
| Key informant | Place of work | Role (if applicable) | Length of interview |
| Pediatrician 1 | Dhulikhel Hospital | Head of Department | 60 minutes |
| Pediatrician 2 | Dhulikhel Hospital | Associate Professor | 53 minutes |
| Pediatrician 3 | Dhulikhel Hospital | Professor | 42 minutes |
| Physician | Dhulikhel Primary Health Care Center | Medical Officer | 35 minutes |
| Municipality Health Officer | Dhulikhel Municipality | Health Coordinator | 38 minutes |
| Public Health Nurse | District Health Office | - | 39 minutes |
| Staff Nurse | Family Planning Association Nepal | Charge Nurse | 40 minutes |
| Non-Governmental Organization | Save the Children | Senior Technical Specialist | 40 minutes |
| Non-Governmental Organization | We WOMEN | Executive | 40 minutes |
Table 1: Focus Group Discussion (FGD) Participants
Table 2: Key Informant Interview (KII) Participants
Awareness of informal human breast milk sharing (Theme 1)
Participants were generally familiar with informal human breast milk sharing. Both personal and community experiences with the use of another mother’s breast milk were acknowledged by many participants, while only pediatricians, physicians and nurses were familiar with screened human donor milk in the hospital setting.
Personal experience
Several participants described their own personal experiences with breast milk sharing, often alluding to desperation or necessity. One mother noted her worry for her child when disclosing her experience:
I was not worried about anything before my childbirth, but after my baby was born, I was worried. My milk was not squeezing out. My baby cries for a whole night out of hunger and so do I. One of the women also had childbirth [and] she fed her breast milk to my baby. Then tomorrow morning, I fed my baby with [infant formula]. After my breast milk was not adequate for my baby, I was worried.
A father described the feeling of having no choice in the matter:
My wife does not have sufficient production of milk, so sister told us to give other’s milk. We did not have any other choice. So, till now, we are feeding like this.
A CHW shared a story of when they were asked to be an informal donor, highlighting multiple different personal experiences:
It happened to me as well. When my baby was sick and is admitted in hospital, one of the women came to me, asking if she can get some milk to her baby as her baby is sick and is crying excessively. I gave her my milk and she is thankful to me till this date.
Some also reported that lactating women may breastfeed another infant directly without expressing milk.
We have found that after delivery they breastfeed their baby here as much as they can and later [when] they are not able to produce breast milk then they are breastfeeding their baby from another woman in the neighborhood who is lactating.
In some cases, if some women are not lactating, in the first 2–3 days, some women are not able to produce breast milk so in such a situation we have found that if there is another mother with a small baby in the neighborhood, they ask to breastfeed their child as well.
Use in community
In addition to first-hand experience, participants referenced hearing about breast milk sharing in the community. It was clear that the majority of participants had at least heard of the practice.
One mother explained:
I have seen in this hospital that one woman was lactating more than enough for her baby, so she expressed her milk and fed another's baby as well.
Another mother in discussion about the topic explained her distant awareness:
I heard long ago that one mother was not lactating, so the baby was fed another woman’s breast milk.
Other CHWs together confirmed their awareness of the practice and then described the communal nature of breast milk sharing:
There are some who do so when they are not able to produce breast milk.
There is the practice of returning favor in the village. [Everybody laughing]
They feed from those mothers who are their relatives.
Fathers agreed that breast milk was usually shared between neighbors or mothers in the same village:
For baby, in village there is practice of giving milk of another mother who have baby. If not, then we give [infant formula] from bottle.
Some of the fathers shared information about their perception of the extent of community breast milk sharing:
Such practice of feeding [shared] milk will be 5% out of 100.
There will be even less as most of the mother does not want other mother milk to feed their child.
If there are own relatives, then they feed.
Lack of knowledge
Although knowledge of use of another mother’s breast milk was common, it was not universal. For example, a public health nurse shared:
I have not heard about donor milk. The mother would rather give cow or buffalo milk because if a mother had to breastfeed other’s baby, then she is also a mother with a baby and she would prefer to feed her own baby instead of others as the milk might not be sufficient for her own baby. So, there is no such practice in this area. Also, in some cases, even if a mother dies during delivery, then the baby is given cow or buffalo milk.
Interestingly, the pediatricians who participated in KIIs generally did not acknowledge informal milk sharing in the community, and instead focused their comments on more formal processes of human donor milk sharing through the hospital or breast milk banks. One pediatrician commented:
This actually in our hospital as well, we have been talking about providing donor milk. Many mothers’ breasts milk has been kept as substitutes. But this kind of practice is not done much outside [the hospital]. Feeding another mother’s breast milk to the baby is done only with the parent’s consent. If a mother is not able to produce breast milk, we do counselling with the parents, but if the mother is really depressed, then she won't be able to. So, we do screen the milk of the donor mother [and] then only we start it.
Another pediatrician expressed confusion about the idea, but referenced the formal idea of breast milk banks:
I have not heard it by saying donor milk, but I have heard about breast milk bank.
Rationale for using another mother’s breast milk (Theme 2)
A major theme that emerged was a need for participants to provide a rationale for breast milk sharing when discussing its use. Rationales usually included references to the barriers to breastfeeding which needed to be overcome or to using breastmilk as a tool for nourishment.
Overcoming breastfeeding barriers
Many different barriers experienced by woman trying to breastfeed were touched on in these interviews. Common breastfeeding barriers included inadequate breast milk supply, mechanical difficulties with breastfeeding, the necessary time commitment of breastfeeding, and religious issues and stigmas associated with sharing breast milk. These were frequently referenced when discussing breast milk sharing.
Inadequate breast milk supply/mechanical difficulties
Mothers talked about their personal experiences with being unable to provide their breast milk to their child. One mother described both having insufficient milk and an inverted nipple which prevented her from breastfeeding normally. She turned to a family member to provide milk for her infant:
My milk is not sufficient for my baby. When I have my first daughter, I have inverted nipple, so I have pulled it out with the help of a syringe for a month. So, I was unable to feed the baby properly. So, my sister-in-law, who was also childbearing woman, fed my first daughter. Her baby was 3 months old. I tried to breastfeed my baby, but my milk was not sufficient, so she fed my baby. I also fed [infant formula] to my child in the first month. My nipple got sore after I used the syringe to pull out my nipple. My nipple got so sore that I can’t even touch it. That’s why my sister-in-law fed her milk and [infant formula] to my baby. My baby only gets to feed little amount of my milk.”
Other mothers similarly expressed problems with sore nipples and milk insufficiency frequently led them to milk sharing:
I had sore nipple, so my older sister fed my baby at hospital.
CHWs also touched on their experiences working with women in the community who faced such difficulties. One CHW described that women frequently turn to their family members for help:
Because here we have been counseling mothers. While coming for follow-up next time, some say milk is fully sufficient for the baby and some mothers say that the baby is constantly crying because milk was not sufficient, so she fed the baby aunt’s breast milk.
Another CHW shed light that some mothers of twins utilize breast milk sharing if they are worried about milk sufficiency:
It is the event of just some days ago, one of my relatives gave birth to twins. Then after that while visiting her mother’s place, she fed them her relative’s breastmilk. Because her milk was not sufficient for both, she fed them her relative’s breastmilk.
Time commitment of breastfeeding
Breastfeeding can be hugely time-consuming, and when mothers must be away from their children for a period of time due to work or other responsibilities, this also led people to engage in breast milk sharing. One of the CHW FGDs had a long discussion about mothers’ use of breast milk sharing as a means to allow flexibility when busy:
It also occurs because some women don't have free time. One goes to work, and if the baby cries, another feed her own breast milk….
Even while visiting here for immunization, mother doesn’t come along with the infant, so if a baby cries, they feed it another mother’s breast milk.
That is because the mother was not available at that time. And the other thing is they feed another mother’s breast milk when its own mother’s milk is not sufficient.
They feed another mother’s breast milk when the mother’s breast milk is not sufficient, the mother is out for work, baby is crying.
Usually, they do so when mother is away for work. When there are two small babies in a household, one goes away for work and there is a small baby, then another feeds her breast milk to the baby.
Mothers confirmed that breast milk sharing is a way to overcome the time constraints of breastfeeding. One mother described:
When I have to go outside, my older sister fed my baby. She feeds my baby whenever my baby cries.
Breast milk as nourishment
Another subtheme of participants’ rationales for breast milk sharing was the ability for breast milk to feed and nourish an infant. Participants reported that breast milk sharing was a way to keep infants from starving and commented on its superiority to other alternatives.
One mother stressed the desperation of the act:
I had fed my eldest daughter in such a way. I was not lactating, so my daughter was starving and crying a lot. So, in order to prevent her from starving, I let my daughter to suckle on my neighbor’s. Not much, just for 2 to 4 times.
Another mother described filling the baby’s stomach as a priority:
It makes baby’s stomach full at the time when they might be starving, so I don't think there will be any challenges as such.
CHWs also commented on this idea of nourishment as a reason for breast milk sharing:
Benefits might be that the hungry baby might get to fill his empty stomach and sleep well.
The infant doesn’t need to stay hungry.
A staff nurse elaborated on the nutritious value of breast milk and sharing breast milk with others:
I have recently seen such activity on television, where a lady goes to a child organization in the morning and breastfeeds the babies the whole day and comes back home at night. I liked that a lot as that organization has taken babies found on the road as well. And what else might be more nutritious than a mother’s breast milk to those babies. The mother’s breast milk contains the antibodies to fight against the diseases.
Hesitancies about use of another mother’s breast milk (Theme 3)
While participants expressed many reasons for choosing to use breast milk from another mother, hesitancies about the practice were also elicited. Participants expressed concerns about potential infectious disease transmission, decreased bonding between mother and infant, and the quality of the donor breast milk provided and its potential incompatibility with mother’s breast milk.
Potential for infectious disease transmission
A common fear expressed by both parents and public health workers was that informal breast milk sharing could lead to disease transmission. A medical officer at a public health care center commented on the risks vs benefits:
As the baby gets nutrition, it has both advantages and disadvantages. We have heard about a case while studying. Its advantage is nutrition and disadvantage are that the mother who was breastfeeding other’s baby, she might have known or not, but she had diagnosed or undiagnosed HIV, and later it got transmitted to the baby. There are really low chances, but maybe she didn't even take antiretroviral therapy at that time.
Many others expressed the same sentiment that they feared this possibility. A CHW stated:
The negative aspect is that if the baby of that another mother is sick, then the baby who is breastfed by that mother might get sick as well.
Another mother confirmed:
If any woman is sick, then the disease might get transferred to the baby.
One father shared how the anxiety around the potential for disease transmission made it much more likely that he would feed his infant animal milks rather than breast milk sharing:
They think positive about giving cow’s and buffalo's milk. But they may be afraid about spreading other mother’s disease to their baby when they allow baby to suck neighbor’s milk. For instance, when my wife does not have sufficient breastmilk, at that time if we need to feed other mother milk, then we feel afraid. We become afraid if that mother has any disease, then it may transfer to our baby. So, nothing is said if cow’s and buffalo’s milk is given.
A staff nurse also commented about disease transmission from breast milk sharing:
In community we might not know what kind of diseases are prevalent in people unless tested. There might also be diseases that might get transferred to babies.
Decreased bonding between mother and infant
Another large hesitation expressed by participants was the potential for lack of bonding between mother and infant. Mothers, fathers, and CHWs all shared similar sentiments in their FGDs.
One mother noted:
There might be less attachment between mother and the baby.
A father further explained how that possibility made him feel:
I do not like feeding other mother’s milk. It is just given to save the life of baby. Mother will have different emotional attachment. When other mother feed, the baby may have less emotional attachment with own mother.
Another CHW similarly felt a strong fear of decreased connection:
The bond between the other mother and the baby will be stronger than the bond between the actual mother and the infant. The love between the actual mother and the child might become weak.
A pediatrician also agreed that the attachment between the mother and child would be decreased:
The disadvantage is there will be a lack of attachment with one's own mother because the baby is breastfed by another mother, so there is lack of bonding with the actual mother. Like it would have been easier to give [Kangaroo Mother Care (KMC)] if breastfeeding is done by the actual mother. If the other mother is breastfeeding the baby like her own, then KMC can be given to that mother. There are no other particular disadvantages.
Incompatibility or insufficiency between donor and mother’s breast milk
Another subtheme that emerged was hesitancy around the quality or incompatibility between donor and mother’s breast milk. Comments were made about the age of the donor mother’s child compared to the age of the receiving mother’s child or the misalignment of the two mothers’ diets.
One FGD of mothers elicited a nuanced conversation about the topic:
I think the women who have older babies, their milk also gets older and when we feed those women’s milk, our baby cannot fully digest the milk and might get stomachache.
Some of the women eat spicy foods, so it might affect the baby’s stomach.
After feeding other women’s milk, our baby might refuse to take our milk.
If other women’s baby is also small, it might not cause problem, but if the other women’s baby is older, they might have taken spicy foods which might cause stomach upset in babies. We had some food restrictions.
A CHW also commented on the difference between breast milks:
Women were scolded by saying there is difference in the milk of older baby’s mother’s milk and newborn baby’s mother milk. It is difficult for the baby to digest that milk.
The sharing of milk by someone who had a miscarriage was also frowned upon in the community. Another CHW described:
One of the women who had miscarriage and she was staying at home, and another woman who has small baby went to work, so her baby was crying excessively. So, she fed her milk to the crying baby but the other people in the neighborhood heard about it and start a fight. The mother-in-law scolded the mother, saying why you are giving the milk of a woman who recently had a miscarriage. That is why community people are afraid to give other women milk.
Furthermore, there was worry that if a mother donated some of her breast milk to another’s child, there would be inadequate breast milk left for her own child. A public health nurse commented:
It is a good deed if we see it from a help point of view, but if a mother shares the breast milk, then it won't be sufficient for two babies because at least one baby would get [in] sufficient breast milk, so I don't like such feeding practice.
A CHW also worried about the same scarcity:
And also, while breastfeeding another mother’s baby, the breast milk might not be sufficient for her own baby.
Another CHW added the advice:
If the mother is doing exclusive breastfeeding and also breastfeeding another mother’s baby as well then, her own baby is being discouraged from exclusive breastfeeding.