The moral economy of human milk banking



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THE MORAL ECONOMY OF HUMAN MILK BANKING
George Kent

University of Hawai'i (Emeritus)



(Draft of August 1, 2015)


Paula's baby Alice Maria was born prematurely. Here, Alice Maria benefits from warmth and bonding with Paula while consuming nutritious breast milk that was withdrawn from the breast milk bank. http://www.unicef.org/infobycountry/brazil_70944.html

In 2013 the twenty deadliest wars in the world resulted in an estimated 127,134 deaths (PS21 2015), while in that same year 6.3 million children died before their fifth birthdays (World Health Organization 2014). The world took little notice of this massive mortality of children, apparently accepting it as normal. Improved nutrition would do a lot to reduce children’s mortality throughout the world.


The best way to improve children’s nutrition is to improve breastfeeding practices. That is well covered elsewhere. This essay focuses instead on the potential for expanding the supply of human milk for children who are not breastfed by their own mothers.
Of the millions of deaths of children under five each year, about 44 percent take place during the neonatal period, the first 28 days of life (World Health Organization 2014). Many vulnerable newborns are cared for in neonatal intensive care units (NICUs) in hospitals. When it is possible, these infants should be breastfed by their own mothers, but often there are impediments. The infant might be too weak to suckle or the mother might be unable to breastfeed for various reasons. Some critically ill infants might get enteral (tube) feeding to their stomachs. In some newborns the gastrointestinal tract is not adequately developed, so they might require parenteral (intravenous) nutrition. Some critically ill newborns might need supplements or medicines of some kind, depending on their conditions.
Making human milk available to critically ill infants should be a high priority, but—the main point here--it should not be limited to them. There are many more children who could benefit from the ready availability of human milk, such as those who get formula. There is now a huge global effort underway by the manufacturers to promote the use of formula by infants and young children, especially in emerging economies with a growing middle class (Kent 2015). The argument here is that to the extent feasible, safe and affordable human milk should be made available to all children who could benefit from it.
A major obstacle to expanding the supply is the view held by many that human milk should not be bought and sold. We do not yet have large-scale empirical evidence to prove that increasing the supply would yield great benefits to children who are not critically ill, but we can make a strong moral argument for it based on what we do know.

RANKING FEEDING METHODS
There is a clear rank order of the quality of infant feeding methods based on their impact on the health of infants and young children. For generally healthy, normal infants, for the first six months the best diet is breastmilk provided through direct breastfeeding by the infant’s biological mother. The key elements of optimal breastfeeding are (a) initiation within one hour following birth, (b) exclusive breastfeeding for six months, and (c) continued breastfeeding for two years and beyond.
Second best would be sub-optimum breastfeeding by the mother, but as close to optimum as possible.
If the difficulties that impede direct breastfeeding cannot be overcome, the next best option would be for the biological mother to express or pump her milk, store it, and then have it fed to her child by herself or another caretaker. For mothers who cannot breastfeed at their workplaces, this may be the best available choice.
Women who do not breastfeed their infants optimally should be counseled and supported in efforts to overcome the difficulties. They should have the support of qualified lactation counselors. The social context also should be arranged to provide maximum support for breastfeeding. Employers should provide paid leave and accommodations for breastfeeding at women’s workplaces, and governments should ensure that high quality information about the likely impacts of different methods of feeding is made available so that parents can make well informed choices about how they will feed their infants.
For infants who cannot get breastmilk from their own mothers, generally the next best option is breastfeeding directly by a carefully screened woman other than the biological mother, as in wet nursing arrangements.
If direct breastfeeding by another woman is not possible, infants and young children can be provided human milk through other milk sharing arrangements or through milk banks.
There is robust scientific evidence that formula is worse for children’s health than breastfeeding. Formula is especially deficient in the fact that it does not have human milk’s ability to strengthen immune systems. Formula-fed children are more vulnerable than those fed with human milk to infections and many other health problems. The cognitive development of children in terms of intelligence and visual acuity is not as good for infant who are fed with substitutes is not as good as it is for those get human milk
If human milk cannot be obtained, the next best option is infant formula, if it can be prepared safely. If it is not prepared safely, perhaps because of poor quality water or other environmental conditions, the formula option is much lower in the rankings. Sub-optimal feeding with formula, like sub-optimal breastfeeding, is bad for children (Burkhardt 2012; Talukder 2014). Both can be sub-optimal in various ways, but in most cases providing human milk is likely to be better than providing formula.
In some countries there are highly advertised national brands of infant formula and also lesser known generic versions, sometimes called “store brands”. An agency that speaks for store brands asserts there is no clear difference in their nutritive value, but the generic ones are much less expensive (Consultant for Pediatricians 2014).
Animal milks such as cow and goat milk are worse for infants’ health than well-prepared infant formula.
At the bottom of the rankings are various other things that are sometimes fed to infants such as fruit juice, tea, and soda. They do not have the nutritional qualities needed by infants, and they can do considerable harm.
This rank order might not apply for infants with special needs such as those who are critically ill or have metabolic disorders. A variety of special infant formulas are sold for these infants, described by the U.S. Food and Drug Administration as exempt infant formulas:
An exempt infant formula is an infant formula intended for commercial or charitable distribution that is represented and labeled for use by infants who have inborn errors of metabolism or low birth weight, or who otherwise have unusual medical or dietary problems (FDA 2014).
The FDA provides a list of them by brand name.
The exempt formulas warrant special scrutiny because they are intended for the most vulnerable infants, but the safety and effectiveness of some of them have not been studied adequately. They are expensive. If they are only moderately effective in providing health benefits, there may be questions about whether they are worth the added costs.

BANKING AND SHARING
Infants normally should be breastfed by their mothers. Many measures can be taken to support that. However, when children are not directly breastfed by their own mothers, for whatever reason, human milk can be supplied to them through banking or sharing.
Banking involves collecting human milk at a central place, processing it, and then having the child’s caretakers obtain the milk from the bank. Some processing is done at the bank, usually screening of the women who provide the milk, pasteurization, and some sort of quality testing. In this arrangement, there is no requirement for contact between the primary providers of the milk and the infant’s caretakers. In contrast, sharing arrangements involve direct contact. For example, advertisements are sometimes placed in newspapers or on the Internet to link the providers to the users. Wet nursing is another form of sharing, with no banking stage between them.
Human milk sharing usually is for infants who are not critically ill and not in hospital settings. In general milk sharing is about improving health while milk banking is about saving lives. However, these lines can be crossed. Some milk banks offer milk to be used outside hospital settings for infants who are not critically ill.
The discussion here is on human milk as a commodity. However, at times it makes sense to focus on breastfeeding as a service. Wet nursing is commonly viewed as a service, and not just a means for transporting a product. That service could be delivered in hospitals as well as home. Instead of making withdrawals from banks, hospitals could maintain lists of screened and certified women who would be called on to directly breastfeed some of their hospitalized infants.
If there were only a single fixed pool of human milk available, one group’s getting more could mean others must get less. Providing human milk to children who are not critically ill might result in depriving those who are critically ill. However, that is not the situation. The amount of human milk produced, the supply, depends on the level of demand. This is true not only for individual infant-woman dyads but also for the larger societal level as well.
It might be possible to increase human milk supplies for infants outside hospitals in a way that enhances the supply for hospitalized infants. To illustrate, milk banks serving children who are not in hospitals could be required to absorb some of the processing costs for milk destined for use in hospitals, perhaps by allowing hospital milk banks to use their equipment. There might be economies of scale under which both groups could benefit. There could be cross-subsidy arrangements under which earnings from providing milk for children outside hospitals could subsidize milk supplies for those in hospitals. There might be ways in which banks and sharing organizations could work together. With creativity, competition between banking and sharing could be replaced by collaboration.

INCENTIVES FOR PROVIDERS
Women, human milk, and breastfeeding have been consistently undervalued, not given the recognition they deserve for their contribution to human well-being. Several observers have argued that the value of human milk should be fully recognized in national accounts and in indicators such as the gross national product, and women should be recognized for its production (Aguayo and Ross 2002; Berg 1973; Hatløy and Oshaug 1997; Oshaug and Botten 1993; Palmer 2009, 319-344; Rohde 1982). In Australia, human milk production is estimated to be worth more than $3 billion a year (Smith 2013).
Some have argued that women should be paid for breastfeeding and other services they normally provide without compensation (Francis et al, 2002). That may not be feasible in relation to feeding one’s own children, but women often are paid when they provide milk for children who are not their own.
There are sharply divided views on the idea of paying for human milk. In sharing, the question is whether the end users should pay the women who provide the human milk. In banking, there are two questions: Should the bank pay the providers? And should the hospital or other end user pay the bank? Payments to milk banks could come from the infant’s family, insurance programs, or government agencies. A variety of cultural and philosophical views are relevant. Government regulation can play a major role.
The Human Milk Banking Association of North America says, “accepting milk donations from volunteer donors is the most ethical way to ensure that milk donations will be shared with the most critically ill of infants.” It argues, “Through following the nonprofit model of milk banking, HMBANA milk banks prioritize infant health when distributing donor milk to fragile infants. When donors contribute their milk to a for-profit breast milk operation, they do not always have the level of certainty about the destination of their donation (PRWeb 2014).”
HMBANA said, “By donating their milk with a nonprofit milk bank, mothers can be sure that their milk will be allocated to the sickest babies in their area.” It is not clear what non-profit status has to do with the fact that human milk providers are not compensated. Also, it is not clear what non-profit status has to do with the credibility of their assurances regarding which infants will get the milk. For-profit organizations could offer similar assurances.
HMBANA suggests that non-profit organizations are inherently more ethical than for-profit organizations but it offers no argument or evidence to support that idea. A milk bank that is nominally non-profit can be exploitative, charging hospitals and others high prices for milk they receive from women who get little or no compensation. Non-profits can be just as exploitative as for-profit organizations.
There is nothing in U.S. law relating to the legal status of nonprofit corporations that says they are not allowed to pay for the goods and services they use. In that law, “nonprofit” means the owners do not make a profit based on that ownership. They may be compensated for specific services they provide to the corporation, like anyone else. Women may be paid for the milk they provide to milk banks even if those banks are organized as nonprofit corporations.
Gabrielle Palmer argues that women should not be paid for their human milk because “altruisim is important to maintain quality”:
Breastmilk donation requires trust between donor and receiver. If a mother expresses her milk for money, then she may be tempted not to tell the milk bank that, for example, she occasionally smokes or that she has had a course of antibiotics. Just as with blood or organ donation, financial incentives can do harm (Palmer 2009, 330).
Similarly, paid providers might be tempted to add cow’s milk or something else to their milk to increase the volume and thus increase the payments they receive. There have been such cases.
There are risks, but relying on altruism through non-payment may not be the best way to deal with them. The risks can be reduced with appropriate monitoring and regulations, and screening of providers. Rather than simply excluding the option of paying for human milk, it is important to weigh the potential benefits against the risks of harm.
Miriam Labbok, a well-known breastfeeding expert, said “offering payment may seem generous . . . or coercive” and added:
The heart of the issue to me is one of availability [of] full unbiased information and free choice among choices in a system that is free of fiscal or personal or health system coercion. Unfortunately, ours is not such a system (Labbok 2015).
Avoiding coercion is important. However, telling women who appear to be well informed that they must not accept payment for their human milk is itself a form of coercion. In its place, measures can be taken to minimize the risks, including the provision of relevant information to all parties to the transaction.
Labbok also said, “When we ask for women to sell their milk when their child is still nursing, we are asking that the milk, even if there is surplus, be denied to their own child (Labbok 2015).” This could happen, and it would be a serious matter. However, Pamela Morrison, another breastfeeding expert, told me:
There could be checks and balances like clinics attached to milk banks attesting to good gain etc. and the nature of breastmilk synthesis being what it is, most women can easily increase their supply to make an ounce or two extra every day over and above what their baby needs - heavens, most women can easily breastfeed twins (Personal Communication, December 29, 2014).
There is a risk that some women who are paid for their milk might for that reason deprive their own infants of their breastmilk. Women who offer their milk should be told they must continue to breastfeed their own infants, and so long as their infants are under six months of age they must be exclusively breastfed. Milk banks could monitor the health of their providers’ infants through visits, by obtaining reports from their health care services, or through direct examination or their infants by pediatric health care workers. The women could be asked to bring in their infants for periodic weighing.
In some cases the financial incentive to mothers might lead them to breastfeed their own children for a longer time than would otherwise: “Andrea breast-fed her daughter Johanna for over a year, in part because of the extra income (Wells 2015).”
While paying women for their milk could lead some to reduce the amount they supply to their own infants, there is potential for another kind of problem at the purchaser’s end of the transaction. Making it easy to obtain other women’s milk could lead some mothers to purchase human milk for their infants rather than breastfeed them directly. Interviewing purchasers about their motivations could reduce that risk. Milk banks could reject women who are reluctant to breastfeed their own children and advise them to seek advice from lactation counselors.
There are other risks as well, especially safety risks of various kinds. The extent to which such negative impacts would actually occur when banking or sharing human milk is an empirical question that should be carefully studied. To some extent the risks can be managed.

FORMS OF COMPENSATION
The line between paying and not paying women for their milk is not sharp and clear. Incentives of various forms could be offered, such as gifts, recognition, rides to and from the collection site, and hospitality at the collection site. Food could be made available for consumption at the site and also to take home. Lactogenic foods or “galactogogues”-- foods that support milk production--would be especially appropriate (Jacobson 2015; Murray 2015).
Similarly, while hospitals and families that obtain milk from the bank might pay a straightforward price per ounce, they might also provide compensation of other forms. There could be fees of various kinds, such as payments for pasteurization and refrigeration services. Hospitals could help to pay for equipment and for campaigns to recruit women to provide their human milk to the bank. They might offer in-kind benefits to milk banks such as salaries, rent-free spaces for their work, and transportation services.
The hospitals may in turn submit bills to the families, health insurers, or governments. The key point here is that it seems unfair to have milk banks get money from hospitals and others who draw from the bank while paying little or nothing to the women who deposit their milk into the bank.
Inadequate incentives to providers or to milk banks could keep the supply too low and the final price too high. In terms of foregone health benefits for children, the “cost” to society of not paying milk providers could be very high.

BANKING AND SHARING AS SOCIAL BUSINESS
In the U.S. banked milk currently sells for about four dollars an ounce. Infant formula made from milk powder can be made into liquid formula for fifteen cents an ounce or even less. In purely economic terms, it is hard for human milk as a commodity to compete with infant formula.
One might think that calling on milk banks to pay the women who provide their milk would increase its final cost, thus making it even less competitive with formula. However, with increased volumes and increased efficiency in banking operations, the selling price of banked milk could be sharply reduced. As its price goes down, buyers who are aware of the inferior nutritional quality of formula would be more likely to opt for human milk.
The feasibility of sharply reducing the price of human milk remains to be tested, in both high and low income countries. It might be done through what has been called social business (Yunus 2007), business designed specifically to deliver social benefits. In some states in the United States such businesses could be established as public benefit corporations. Groups of entrepreneurial breastfeeding advocates could start milk bank businesses with the primary purpose of improving children’s health. They would recognize that money would have to be earned to cover the expenses of the operation. That would include providing suitable incentives to the women who provide the milk and also paying the workers who operate the bank.
There would be a variety of problems to overcome, as in any business startup. If the managers of the project were mainly interested in the “bottom line” of improving children’s health rather than the bottom line of taking home a lot of money, it could work well.
As a matter of policy, some or all of these enterprises could be managed and perhaps owned entirely by women. Men could help in the start-up phase, but following that start-up period, men could be limited to advisory roles, as determined by the managers.
These enterprises could begin as small pilot projects, with well-chosen advisors who would seek ways to allay fears about safety and other concerns. Nongovernmental professional organizations and appropriate bodies of government could develop systems for regulating these enterprises. Transparency in financial arrangements could help to limit abuses.
Such initiatives could lead to the creation of many small businesses. Some would succeed and some would fail, and a great deal would be learned in the process. National governments could establish central offices to oversee them.
Another approach would be to set up one large business with a strong central headquarters controlling many local businesses. Mother’s Milk Bank based in Colorado demonstrates possibilities for running a network based on having a strong headquarters operation supported by Donor and Outreach Centers throughout the country (Briggs 2015; Mother’s Milk Bank 2015). It might be sensible to adapt methods used by large fast food chains, with local franchises operating under guidance from headquarters. Each of the businesses could be separately owned, raising its own startup capital, and operating under clear rules established by the company’s headquarters. The headquarters could provide a variety of services to the franchise holders.

CONCLUSION
The ethical imperative for compensating women for the human milk they provide for other people’s children is strong. With good management:


  1. It would be fair to compensate women who provide human milk for others’ children.




  1. With compensation to providers there would be a larger supply so more children would be able to receive human milk rather than substitutes such as formula.




  1. With more children getting human milk rather than substitutes, their health and well-being would be substantially improved




  1. With a larger supply, the cost for human milk would be lower.




  1. The money that goes to formula manufacturers would be better spent if it went to women, especially women with low incomes.

The buying and selling of human milk can be done badly but it also can be done well. It is possible to learn from successes and failures in current practices to establish appropriate guidelines and rules to govern the buying and selling process.


Where there is disagreement about the merit of paying for human milk, one option would be to allow individuals and agencies to operate on the basis of donations if they wish, and allow others to accept payments. This would be less coercive than a policy that requires all agencies to follow the same rules regarding payment.
No one asks farmers or infant formula manufacturers to offer their products free as a way of ensuring their integrity. Why should women who offer human milk for sale be treated differently than, say, people who offer their labor for sale? If women were paid for their milk, more children would get a good start in life. The potential benefits of expanding the supply of banked human milk are large and the risks of harm are manageable.

REFERENCES
Aguayo, Victor M. and Jay Ross 2002. “The monetary value of human milk in Francophone West Africa: A PROFILES analysis for nutrition policy communication.” Food and Nutrition Bulletin, Vol.23, No. 2, pp. 153-161. https://www.researchgate.net/publication/11280558_The_monetary_value_of_human_milk_in_Francophone_west_Africa_a_PROFILES_analysis_for_nutrition_policy_communication
Berg, Alan 1973. The Nutrition Factor. Washington, D.C.: Brookings Institute. http://www.ncbi.nlm.nih.gov/pubmed/22114199
Briggs, Austin 2015. “Relocated milk bank in Arvada feeds premature and other babies.” The Denver Post Yourhub Arvada. July 23. http://www.denverpost.com/arvada/ci_28517543/relocated-milk-bank-arvada-feeds-premature-and-other
Burkhardt MC, Beck AF, Kahn RS, Klein MD. Are our babies hungry? Food insecurity among infants in urban clinics. Clinical pediatrics. 2012 Mar;51(3):238-243. http://www.ncbi.nlm.nih.gov/pubmed/22114199
Consultant for Pediatricians 2014. A Comprehensive Overview of Store Brand Infant Formula. February. http://www.pediatricsconsultant360.com/sites/default/files/Perrigo_Advert%20small.pdf
FDA 2014. Exempt Infant Formulas Marketed in the United States by Manufacturer and Category. Washington, D.C.: U.S. Department of Health & Human Services. Food and Drug Administration. http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/InfantFormula/ucm106456.htm
Francis, Solveig; Selma James, Phoebe Jones Schellenberg, and Nina Lopez-Jones 2002. The Milk of Human Kindness. London: Crossroads.
Hatløy, Anne and Arne Oshaug 1997. “Human Milk: An Invisible Food Source. Journal of Human Lactation. Vol. 13, No. 4 (December), pp. 299-305.
Jacobson, Hilary 2015. Lactogenic Foods and Herbs. MOBI: Motherhood International. http://www.mobimotherhood.org/lactogenic-foods-and-herbs.html
Kent, George 2015. “Global infant formula: monitoring and regulating the impacts to protect human health.” International Breastfeeding Journal, 2015, Vol. 10, No 6. DOI: 10.1186/s13006-014-0020-7 http://www.internationalbreastfeedingjournal.com/content/10/1/6/abstract
Labbok, Miriam 2015. “Paying Moms for their Milk – a slippery slope.” Breastfeeding4Health. January 12. http://www.breastfeeding4health.com/2015/01/paying-moms-for-their-milk-slippery.html
Mother’s Milk Bank 2015. Website. http://rmchildren.org/mothers-milk-bank/
Murray, Donna 2015. Galactogogue: How to Make More Breast Milk. About Health. http://breastfeeding.about.com/od/milksupplyproblems/g/Galactagogue.htm
Oshaug, Arne and Grete Synøve Botten 1993. “Human milk in food supply statistics.” Food Policy. Vol. 19, No. 5, pp. 479-482.
Palmer, Gabrielle 2009. The Politics of Breastfeeding: When Breasts are Bad for Business. London: Pinter & Martin.
PS21 2015. Death Toll in 2014’s Bloodiest Wars Sharply Up on Previous Year. PS21 Project for the Study of the 21st Century. https://projects21.files.wordpress.com/2015/03/ps21-conflict-trends.pdf
Rohde, Jon Eliot 1982. “Mother milk and the Indonesian economy: A major national resource.” Journal of Tropical Pediatrics. Vol. 28, No. 4, pp. 166-174.
Smith, Julie 2013. “’Lost Milk?’: Counting the Economic Value of Breast Milk in Gross Domestic Product.” Journal of Human Lactation. Vol. 29, No. 4, pp. 537-546. https://www.researchgate.net/publication/249322424_Lost_Milk_Counting_the_Economic_Value_of_Breast_Milk_in_Gross_Domestic_Product
Talukder, M. Q-K; Nasneen Akhter Banu; and Khurshid Talukder 2014. Tragedies of Infant Formula and Sub-optimal Breastfeeding. Mirpur, Dhaka, Bangladesh: Bangladesh Pediatric Association. http://ibfan.org/docs/Tragedies-of-Infant-Formula-and-Sub-optimal-Breastfeeding.pdf
World Health Organization 2014. Children: Reducing Mortality. Geneva: WHO. http://www.who.int/mediacentre/factsheets/fs178/en/#
Yunus, Muhammad 2007. Creating a World Without Poverty: Social Business and the Future of Capitalism. New York: Public Affairs.







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