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Awareness, attitudes and barriers towards donor human milk banking: A cross-sectional study
*Corresponding author: Keerthidarshini Khanappanavar, Assistant Professor, Department of Pediatrics, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India. keerthidarshini@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Wari PK, Khanappanavar K, Ratageri VH, Likhita S, Madura M. Awareness, attitudes and barriers towards donor human milk banking: A cross-sectional study. Karnataka Paediatr J. doi: 10.25259/KPJ_65_2025
Abstract
Objectives:
Donor human milk (DHM) is globally recognised as the preferred alternative when maternal milk is unavailable, especially for pre-term and low birth weight infants. Human milk banks (HMBs) ensure safe collection, screening, pasteurisation, storage and distribution of milk under strict protocols. Awareness, attitudes and perceived barriers are pivotal in sustaining donor recruitment and HMB programs. The objective of this study is to assess awareness, attitudes, and barriers regarding DHM and HMB among mothers and nursing officers in a tertiary hospital, and to identify predictors of willingness to donate.
Material and Methods:
A descriptive cross-sectional survey was conducted amongst postnatal mothers and nursing officers using a pre-tested structured questionnaire. Data were analysed using descriptive statistics, Chi-square tests and multivariable logistic regression. Adjusted odds ratios (aOR) with 95% confidence intervals were reported.
Results:
Of 100 participants (92 mothers, 8 nursing officers), 77% had heard of DHM, 51% knew its benefits and 71% were aware of the hospital’s HMB. Among mothers, 58% expressed a willingness to donate, 29% were unsure, and 5% declined. Barriers included lack of awareness (75%), cultural/social stigma (27%) and safety concerns (26%). Independent predictors of willingness were prior awareness of DHM (aOR 10.70, P = 0.0026), comfort with DHM use (aOR 4.91, P = 0.017) and knowledge of benefits (aOR 4.74, P = 0.021).
Conclusion:
Willingness to donate was influenced by awareness, knowledge and comfort with DHM. Targeted education, peer support and transparent communication about safety may improve donor recruitment and strengthen HMB programs.
Keywords
Attitudes
Awareness
Barriers
Donor human milk
Human milk banking
INTRODUCTION
Breast milk is universally regarded as the optimal source of nutrition for infants, providing essential nutrients and immunological protection that reduce neonatal morbidity and mortality. When a mother’s own milk is unavailable, donor human milk (DHM) is recommended as the best alternative, particularly for preterm and low-birth-weight infants.[1,2] Human milk banks (HMBs) play a critical role in this process by ensuring the systematic collection, rigorous screening, pasteurisation, safe storage and regulated distribution of DHM under established safety protocols.[3]
Despite these well-documented benefits, the success of HMBs depends heavily on donor recruitment and community acceptance. In many low- and middle-income countries, this remains a major challenge. Barriers such as cultural stigma, lack of awareness, misconceptions regarding safety and limited health education contribute to the low rates of milk donation.[4-6] Concerns about infection transmission, doubts about the adequacy of pasteurisation, and traditional beliefs often discourage mothers from donating. Furthermore, systemic issues such as inadequate infrastructure, the absence of strong policy frameworks, and heavy clinical workloads among healthcare providers exacerbate these challenges.
Understanding awareness, attitudes, and perceived barriers among both mothers — the primary potential donors — and nursing officers, who are often frontline facilitators in neonatal care, is essential for designing effective interventions for donor recruitment. Their perspectives provide complementary insights: while mothers represent the donor pool, nursing officers are instrumental in counselling, motivating and guiding families through the donation process.
The present study was undertaken to evaluate awareness, attitudes and barriers towards DHM and HMB in a tertiary care hospital. Importantly, it also aimed to compare the perspectives of postnatal mothers and nursing officers, thereby addressing a secondary objective of identifying potential differences between these two key stakeholder groups. This dual perspective is expected to provide a more comprehensive understanding of the determinants of willingness to donate and inform strategies to strengthen HMB services in similar settings.
MATERIAL AND METHODS
Study design and participants
A descriptive cross-sectional survey was conducted at a tertiary care teaching hospital. The study population included two groups: postnatal mothers admitted to the maternity wards and nursing officers working in the neonatal intensive care unit. This dual inclusion was intentional, as mothers represent the primary potential donors, while nursing officers serve as key facilitators of donation and HMB services.
Sampling
A convenience sampling technique was employed to recruit participants. While this approach was pragmatic in a hospital setting, it is acknowledged that convenience sampling may introduce selection bias, as participants were not randomly selected. This limitation is considered in the interpretation of results.
Data collection
Data were gathered using a structured and pre-tested questionnaire designed to capture socio-demographic characteristics, awareness of DHM and HMB, attitudes towards donation and use and perceived barriers. The questionnaire also included items on willingness to donate, comfort with DHM use and knowledge of milk banking practices. Prior pilot testing ensured face validity and comprehensibility of the tool.
Data management and analysis
Responses were entered into Microsoft Excel and analysed using Python statistical packages (Pandas, SciPy and Statsmodels). Descriptive statistics were used to summarise categorical variables in terms of frequencies and percentages. Associations between socio-demographic factors and awareness of or willingness to donate were tested using the Chi-square analysis. Effect sizes were estimated using Cramér’s V where appropriate. Variables significant at P < 0.05 in univariate analysis were subsequently entered into multivariable logistic regression models to identify independent predictors of willingness to donate. Adjusted odds ratios (aOR) with 95% confidence intervals were reported. Statistical significance was defined as P < 0.05 for all analyses.
RESULTS
Participant characteristics
A total of 100 individuals participated in the study, comprising 92 postnatal mothers and 8 nursing officers. Educational backgrounds varied: 9% had no formal education, 43% had completed primary schooling, 35% had completed secondary schooling, and 13% were graduates or held nursing degrees. This distribution reflects a heterogeneous sample, with nursing officers representing a smaller but important subgroup for comparative insights [Table 1].
| Characteristic | n (%) |
|---|---|
| Total participants | 100 (100%) |
| Mothers | 92 (92%) |
| Nursing officers | 8 (8%) |
| Primary school | 43 (43%) |
| Secondary school | 35 (35%) |
| No formal education | 9 (9%) |
| Graduate/B.Sc Nursing | 13 (13%) |
Awareness and attitudes
Overall, 77% of participants reported having heard of DHM, while just over half (51%) were aware of its specific benefits. Awareness of the hospital’s HMB was present in 71% of respondents. Among mothers, 58% expressed a willingness to donate milk, 29% were undecided, and 5% declined. In terms of attitudes, 74% rated breast milk as “very important” for infant health, and 72% indicated they were comfortable with the concept of DHM use.
Barriers to donation
When asked about barriers, the most frequently cited factors were a lack of awareness (75%), followed by cultural or social stigma (27%), safety concerns regarding infection or contamination (26%), and a perceived lack of healthcare support (15%). These findings highlight both informational and systemic challenges that influence donation behaviour.
Determinants of willingness to donate
Univariate analysis using Chi-square tests demonstrated significant associations between willingness to donate and both prior awareness of DHM and comfort with its use. Education level also showed a correlation with awareness of benefits.
Multivariable logistic regression identified three independent predictors of willingness to donate: having prior awareness of DHM (aOR 10.70, P = 0.0026), being comfortable with DHM use (aOR 4.91, P = 0.017) and knowledge of its benefits (aOR 4.74, P = 0.021). These findings suggest that experiential and informational factors outweigh socio-demographic variables, such as formal education, in influencing donation behaviour [Table 2].
| Predictor | aOR | 95% CI | p-value |
|---|---|---|---|
| Heard of DHM | 10.7 | 2.29–50.07 | 0.0026 |
| Comfortable with DHM | 4.91 | 1.32–18.24 | 0.017 |
| Aware of DHM benefits | 4.74 | 1.27–17.72 | 0.021 |
| Education level | NS | — | >0.64 |
DHM: Donor human milk, aOR: Adjusted odds ratios, CI: Confidence intervals, NS: Not significant. p value < 0.01 is significant.
DISCUSSION
This study provides important insights into awareness, attitudes and barriers regarding DHM and HMBs in a tertiary care setting. The findings indicate that awareness of DHM was relatively high (77%), yet knowledge of its specific health benefits was limited to just over half of the respondents. This highlights a significant knowledge gap that has also been reported in previous Indian and international studies.[1,4,5]
Predictors of willingness to donate
The analysis demonstrated that willingness to donate was most strongly influenced by prior awareness, comfort with the use of DHM, and knowledge of its benefits. Mothers who had heard of DHM were more than 10 times as likely to express willingness to donate. Similarly, comfort with the use of DHM and recognition of its benefits independently increased the likelihood of donation. These findings are consistent with evidence suggesting that targeted and culturally sensitive educational interventions improve acceptance and willingness to donate.[4,5]
Interestingly, formal education level was not an independent predictor after adjustment for other variables. This implies that literacy alone does not determine donor behaviour; rather, exposure to relevant, accessible information and counselling plays a more critical role. Thus, structured antenatal classes, peer counselling and proactive engagement by healthcare providers may be more effective strategies for donor recruitment than relying on general education status.[7,8]
Barriers to donation
The most common barriers reported were a lack of awareness (75%), followed by cultural and social stigma (27%), and safety concerns (26%). These results are in line with previous literature, which emphasises that misinformation and cultural taboos remain powerful deterrents to milk donation.[6,9,10] Concerns over safety and infection transmission can be alleviated by transparent communication about rigorous donor screening, pasteurisation and quality control protocols, which are internationally standardised and have been shown to maintain milk safety.[11]
Cultural barriers, such as traditional beliefs about sharing breast milk, continue to pose a challenge to address. Community-level interventions, including engagement of peer counsellors, involvement of community health workers and mother-to-mother support groups, have shown promise in breaking stigma and improving acceptance.
Systemic and policy-level challenges
In addition to individual-level barriers, systemic challenges — including limited infrastructure, insufficient policy frameworks, and the heavy workload of healthcare providers — pose obstacles to scaling up HMB services. The Brazilian model, which integrates milk banks within community and primary healthcare services, has demonstrated both cost-effectiveness and long-term sustainability.[12] Adapting similar models within the Indian context could help overcome systemic barriers and strengthen the HMB network.
Implications for practice and research
This study underscores the importance of focusing on awareness-building and comfort with DHM as central determinants of willingness to donate. For clinical practice, incorporating DHM education into antenatal and postnatal counselling sessions, using peer champions and ensuring transparent messaging around safety can improve donor recruitment. At the policy level, scaling up HMBs and integrating them into routine maternal and child health services should be prioritised.
Future research should adopt multi-centre designs with larger and more balanced samples, as well as mixed-methods approaches that combine quantitative data with qualitative exploration of cultural and systemic barriers. This would provide a more comprehensive understanding of determinants of donor behaviour and inform more effective interventions.
Strengths and limitations
This study included both mothers and nursing officers, offering dual perspectives. Multivariable analysis identified independent predictors. Limitations include a single-centre design, a small sample and overrepresentation of mothers. Self-reported responses may be biased, and the cross-sectional design restricts causal interpretation.
CONCLUSION
Willingness to donate was associated with prior awareness, knowledge of benefits and comfort with DHM. Targeted education, transparent communication and culturally appropriate outreach are essential to improve donor recruitment. Larger, multi-centre, mixed-methods studies are needed to explore cultural and systemic barriers.
Ethical approval:
The Karnataka Medical College and Research Institute, Hubbali Ethics Committee has approved the research study, approval no: KMCRI:ETHICSCOMM:73:2025-26, approval date is 12th August 2025.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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