Attitudes towards human milk banking among native turkish and refugee women residing in a rural region of Turkey: a mixed-methods approach

Based on the qualitative study, a conceptual framework with six main themes including awareness of the importance of breast milk, knowledge and attitudes toward wet nursing, knowledge about HMB, attitudes toward HMB, positive opinions about HMB, and negative opinions about HMB was created.

The sociodemographic characteristics of the women (n = 271) who participated in the survey are shown in Table 1. The mean age of the women included in the quantitativestudy was 26.82 ± 4.89 years; 84.5% lived in nuclear families and 44.6% had one child (Table 1).

Table 1 Sociodemographic characteristics of survey participants (n = 271)

Fifteen women (n = 33) included in the qualitative study were refugees. These women were aged 21 to 40 years and had one to three children.

The women’s knowledge and attitudes toward breastfeeding, wet nursing, and HMB are shown in Table 2.

Table 2 Women’s knowledge of and attitudes towards breastfeeding, wet nursing and human milk banking (n = 271) Awareness of women about the importance of breast milk

Sixty-seven point two per cent of the women reported that they exclusively breastfed their babies in the first six months. Only 2.7% of the mothers reported that they did not breastfeed their babies in the first six months.

Almost all of the native and refugee women reported that they were aware of the importance and benefits of breastfeeding, and the superiority of breast milk to infant formulas. “There is nothing like breast milk; better than everything, it’s so good. Breast milk is very important for the baby’s development. Instead of giving formula, breast milk is much more precious. I think breast milk can be in no way harmful. Breast milk, how do they say, like antibiotics for the health, I think it can no way be harmful. [D.D., 23 years, N] A refugee mother said: “Every baby who needs it should get breast milk. It is a good thing. Breast milk is healthier, I exclusively breastfed my baby, no formula, only breast milk.” [S.B., 38 years, R].

Women’s knowledge of and attitudes towards wetnursing

Eighty-eight point six per cent of the women had heard about wet nursing, and 12.5% had an experience of breastfeeding someone else’s baby. Seventy-seven point nine per cent reported that they could be wet nurses for other babies, 7.7% reported that their babies had had wet nurses, and 34.3% reported that other people could breastfeed their babies if they did not have enough milk.

In IDIs, most of the mothers said that they had known of wet nursing as a concept for a long time although they had no first-hand experience with wet nursing. “Back in the old days, mothers used to breastfeed each other’s babies when they did not have enough breast milk. Like milk siblings, I used to hear stories about these from my mother.“ [E.K., 22years, N].

Some of them also said that they have had personal experience with wet nursing. “For example, my neighbor breastfed my child in the beginning. My mother-in-law breastfed this neighbor’s children and my child was breastfed by them, so it’s all a twist of faith.“ [N.K., 22 years, N] Similarly, refugee women reported that they knew about wet nursing and had experienced wet nursing in their lives. “My mother-in-law used to talk about this when we were living in the village in Syria; then I breastfed my big sister’s daughter. Old people, our elderly, used to talk about; there used to be a lot of wet nurses.“ [Z.A., 23 years, R].

Women’s knowledge about human milk banking

Seventy-four point nine per cent of the women reported that they had never heard of HMB. Among those who reported that they had heard about HMB, 65.7% heard about it on social media, 20.9% heard about it from healthcare professionals and 13.4% heard about it from their friends.

Although some of the women reported that they had heard about HMB during IDIs, no native or refugee women had any specific knowledge about how HMBs work. “I have never heard about human milk banks; I have heard about eye banks, blood banks, but never heard about this.” [L.D., 32 years, N].

Women’s attitudes towards human milk banking

Fifty-seven point nine per cent of the women were willing to donate breast milk, whereas only 27.7% were willing to use donor milk for their babies. Fifty-nine per cent of the women reported a positive attitude towards HMB (donor or recipient), and 53.1% of the respondents reported that they would prefer to have an HMB in Turkey; 32.5% were indecisive about this.

In IDIs, women generally stated that they would donate their milk to an HMB but would not take milk from the HMB for their children. “I would donate breast milk but I would not give donor milk to my child. I would think about how they collect and store such milk. I think formula would be healthier. I am a little obsessed about hygiene, so I would not be comfortable.“ [K.Ş., 33 years, N] “I think this is a good idea; babies who could not be breastfed could have breast milk instead of formula. I think this would be more logical, but I don’t know if I would take milk from the bank.“ [N.Y., 22 years, R].

Women’s negative opinions about human milk banking

Fifty-nine per cent of the women (160 women) who participated in the survey reported any type of negative opinion. Of the women who reported negative opinions, 76.3% gave religious concerns; 52.5% feared infectious diseases; 42.5% reported that they did not trust people; 22.5% reported that there were infant formulas today as alternatives to breast milk; 17.5% reported fear of allergies; 6.9% reported that they wanted their babies to be breastfed only by them; and 5.6% reported fear of spoiled milk as their reasons for their negative opinions about HMB.

In IDIs, women’s negative opinions about HMB were mostly about “receiving donor milk”. During IDIs, no one reported a negative attitude about “donating milk” except for religious concerns. “Because there is a possibility of becoming milk siblings, I neither donate nor receive milk. I would not donate; I mean if there had been no such thing as milk siblings, I would have both donated and received milk. Let’s say they will get married in the future, how will I know, so it’s a sin. So, instead of giving milk of somebody who I have never met, I’d rather feed my child with milk of somebody I know. Of course, I would not want to deprive that child of milk.” [H.D., 33 years, N].

In particular, native women spoke of the fear of infectious diseases as the reason for their negative attitude towards receiving donor milk from an HMB. There were no refugee women who gave this as the reason. “No, I would not feed my baby with donor milk. I would not feel comfortable, I don’t know how I can explain. I would not want to give somebody else’s milk; I would worry that my baby would get infected, sick. For me it is better to give formula; I mean, it does not make sense to me.“ [N.E., 34, N].

Another negative opinion was the feeling of “distrust”. During IDIs, women expressed distrust in two different ways: “distrust in people they do not know” and “distrust because of infectious diseases”. Native women often underlined the above-mentioned statements, whereas most of the refugee women gave “distrust in people they do not know” as the reason for their negative attitudes. “I don’t know whether I would trust and receive milk? I guess I would not want to give donor milk to my children. I mean, let’s face it, we don’t know what kind of people donate milk. I don’t know what’s in it, of course, we know that breast milk is natural but can we trust anyone with our child? No. Giving somebody else’s milk is the same thing. I think we can’t do that. Of course, I would want to give the milk of people whom I know and trust. I would feed my child with their milk and I would give my milk to their children. [A.T., 28 years, N]

Women’s positive attitudes towards human milk banking

Forty-one per cent of the women (111 women) who participated in the survey reported any type of positive opinion. Seventy-two per cent of the women with positive attitudes toward HMB gave the reason that babies who could not be breastfed could still have breast milk; 65.8% gave the reason that they trusted breast milk; 58.6% gave religious reasons; and 40.5% reported that they trusted healthcare professionals / the ministry of health.

IDIs showed that there were women with a positive attitude towards HMB. Positive attitudes were mostly based on knowing the “importance of breast milk”. One of the main reasons for positive attitudes among native and refugee women toward HMB was that “babies who cannot be breastfed can still benefit from breast milk.“ “I wish we could have places like this (HMB); thank God my children never needed wet nurses. I always breastfed myself; I didn’t even give formula milk but there are many children who cannot be breastfed. Let those who do not have breast milk have breast milk”. [B.A., 27 years, N] “Breast milk is very important, those who have give to those who don’t. This is especially good for abandoned children. I feel very sad for them, I wish they could have breast milk at least until they are 6 months old”. [D.A., 28 years, R]

Additionally, although religious factors were generally the reasons for negative attitudes, they also played a role in positive attitudes. The IDIs found that both native and refugee women thought that it was a “good deed” in a religious sense to feed a baby in need. “I don’t see anything bad in this. If you ask why, for example, if a 1-month-old baby cannot be fed with breast milk, it is a very bad sin. That child needs breast milk. It is better to give the child breast milk. Let’s say, God bless, think about a baby who cannot be breastfed and suffer in a hospital. My baby can be breastfed, comfortable, but that baby there is hungry, this is a sin.“ [A.T., 28 years, N] “It is a very good deed to feed a hungry child, if that child stays hungry, then it is a sin. God forbid; if I give milk, that child can maybe live. If there was a bank here, I would donate.“ [B.S., 23 years, R].

In addition to these factors, trust in healthcare professionals and public health institutions was given as the reason for positive attitudes in native women. “If it is approved by the ministry of health, by you, then it is good for me. But if it is something done by a normal citizen, I will not feel comfortable. I mean, I think they always check and quality control everything, packaging and then allow. [G.B. 29 years, N]

Factors for attitudes of women towards human milk banking

Factors for attitudes of women toward HMB are shown in Table 3. The odds of having positive attitudes toward HMB were 4.19 times higher in homemaker women (95% CI 2.0, 8.76) compared with those who worked; 4.77 times higher in women with three or more children (95% CI 1.25, 8.15) compared with those who had fewer children; 6.12 times higher in women who had a positive attitude towards wet nursing (95% CI 3.14, 9.63) than those who did not; and 2.68 times higher in those who had previously heard about HMB (95% CI 1.24, 5.79).

Table 3 Factors associated with having a positive attitude about human milk banking

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