Japanese Mothers’ Experiences and Sentiments Towards Donor Human Milk for Very Low Birth Weight Infants: A Modified Grounded Theory Approach

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When mothers’ own milk (MOM) is temporarily unavailable, donor human milk (DHM) is used as an alternative. In Japan, where human milk banking has been introduced relatively recently, little is known about how mothers experience emotional changes and social interactions related to DHM use while continuing to express their own milk. Method Semi-structured interviews were conducted with 10 mothers of VLBWIs who had used DHM immediately after birth, and data were analysed using the Modified Grounded Theory Approach. Results Mothers experienced a conflict between their genuine feelings and the realities of donor human milk use; however, the words of those who stayed beside them, including midwives and physicians, facilitated meaning-making, enabling mothers to reconcile their experiences through expressing milk and their infant’s growth. 【Words from those who stay beside the mother】 provided insights for clinical nursing practice. Continued breastfeeding and the child’s growth supported mothers in negotiating and reconciling the tension between their authentic feelings and the realities of using donor human milk. Conclusion This study clarified how mothers negotiate and reconcile emotional conflicts related to DHM use in NICUs. Emotional support from healthcare professionals, together with ongoing lactation support and opportunities to share experiences, may help mothers come to terms with DHM use and sustain milk expression. These findings provide practical implications for nursing support in settings where DHM is implemented. Providing continuous lactation support and opportunities to share experiences may help mothers come to terms with DHM use and sustain milk expression. Additionally, building connections among mothers, creating opportunities for peer gatherings, offering antenatal education that includes breastfeeding preparation, and enhancing lactation education for healthcare professionals are beneficial. These findings offer practical implications for breastfeeding support in settings where DHM is implemented. Donor human milk Modified grounded theory approach Neonatal intensive care unit Mother’s own milk Very low birth weight infants Figures Figure 1 Introduction According to UNICEF’s State of the World’s Children 2024 , the global average neonatal mortality rate is 1.7%, whereas Japan reports a rate of 0.1% of live births, reflecting substantial advances in perinatal and neonatal care 1) . Advances in medical care have led to Japan’s low neonatal mortality rate, indicating that it has one of the safest and most advanced healthcare systems worldwide. However, its proportion of very low birth weight infants (VLBWIs) has been increasing. Between 1980 and 2019, the proportion of VLBWIs (< 1,500 g) increased from 0.3% to 0.7%, while that of extremely low birth weight infants (ELBWIs) (< 1,000 g) also rose from 0.1% to 0.3% 2) . Infants admitted to neonatal intensive care units (NICUs) are mainly preterm or with low birth weight, immature immune systems, and a high risk of developing complications, such as necrotising enterocolitis (NEC). Sato et al. reported that the mortality rate of NEC with intestinal perforation among infants in NICUs reached 58% 3) . Furthermore, Quigley et al. indicated that formula feeding increased the mortality risk associated with intestinal necrosis by 1.87 times 4) . In NICU infants, breast milk serves as a source of nutrition and plays a vital role in preventing complications. A higher proportion of human milk in enteral feeding has been associated with lower incidences of NEC, bronchopulmonary dysplasia, retinopathy of prematurity, and late-onset sepsis 5) . Moreover, breast milk has been shown to improve long-term cognitive and motor development 6) . Recognising its benefits, mothers initiate milk expression for their infants. Conversely, regardless of their infants’ health condition, mothers strongly desire to breastfeed, perceiving it as a ‘natural’ act and an essential ‘maternal role’ that they are expected to perform 7) . However, due to factors such as mother–infant separation, stress, and underdeveloped mammary glands resulting from premature birth, mothers may experience difficulties producing sufficient breast milk in the early stage 8) . Therefore, the World Health Organisation recommends using donor human milk (DHM) to prevent life-threatening NEC 9) . To ensure that mothers’ own milk can be provided immediately, Japan has also made DHM available as a temporary substitute by establishing human milk banks in 2017 10) . Although several studies have examined DHM’s effects and composition, research focusing on the experiences and feelings of mothers using DHM remains limited. Previous studies have shown that mothers wish to be the sole providers of breast milk for their infants, and they may experience anxiety or reluctance about giving DHM because of infants’ health concerns 11) . However, mothers’ feelings after childbirth are dynamic and fluctuate based on interactions with those around them. Therefore, their perceptions of DHM may also change through these interactions. As human milk banks are being established in an increasing number of countries, particularly in regions where DHM has been introduced relatively recently, understanding mothers’ emotional and relational experiences during this early implementation phase is crucial. Cultural expectations regarding breastfeeding and maternal roles may influence how mothers interpret the use of DHM, yet little is known about these processes in newly adopting contexts. This study aimed to clarify the process through which mothers with infants in NICUs, who decided to use DHM while expressing their own milk, experienced and developed their thoughts and emotions regarding their infants and social interactions, to identify implications for nursing support. Method Study Design This qualitative study employed semi-structured interviews and was analysed using the Modified Grounded Theory Approach (M-GTA) to explore process-oriented maternal experiences. Study Setting This was a single-site study at a 21-bed Japanese university hospital’s NICU, providing specialised care for VLBWIs, following standard DHM protocols. Participants They comprised mothers: 1) whose infants met the eligibility criteria outlined in the Japanese guidelines for initiating DHM use—birth weight <1,500 g or a gestational age of <32 weeks; 2) who had initiated milk expression and were using DHM for the first time; 3) whose infants were hospitalised in the NICU; 4) who had completed 2–3 weeks since birth and both mother and infant were clinically stable; 5) who had established a positive attachment to their infants and provided informed consent to participate in the study. Exclusion criteria comprised mothers: 1) with comorbid psychiatric disorders, difficulty communicating with the researcher, poor acceptance of the infant, and lack of breast milk; 2) whose infants received DHM due to underlying medical conditions, and had chromosomal or genetic abnormalities, unstable conditions, or poor prognosis; and 3) who did not provide informed consent. Ethical Considerations This study was approved by the Nara Medical University Ethics Committee (approval no. 3885) on November 1, 2024. Written informed consent was obtained from all participants prior to participation. Data Collection Qualitative data were collected through interviews conducted between November 2024 and August 2025. Potential participants were recruited by the principal investigator—a midwife working in the NICU—and co-investigators based on the inclusion and exclusion criteria. To avoid any sense of coercion, the co-investigators first obtained preliminary consent from participants. Care was taken to ensure participants understood that participation was entirely voluntary. Specifically, the study information sheet clearly explained that non-participation would not affect their infants’ treatment or nursing care in any way, and that they could withdraw at any time, even after giving preliminary consent. Thereafter, participants’ written informed consent was obtained, and they were asked about their prenatal intentions regarding breastfeeding and their current milk expression status, using a data collection sheet. Subsequently, semi-structured interviews lasting approximately 30–60 minutes were conducted using an interview guide developed specifically for this study. The interviews explored mothers’ experiences and perceptions, including support for continuing milk expression, their initial reactions upon learning about DHM, their decision to use DHM, their current feelings towards DHM, their thoughts regarding their role as mothers and their infants while continuing to express milk, and the support and guidance they considered necessary. Data Analysis Data were analysed using a modified grounded theory approach (M-GTA), which emphasises the perspective of direct social interactions between individuals and is particularly suitable for process-oriented phenomena. It is a qualitative research method that generates original theories through data-driven analysis, aimed at the practical application of the resulting theory 12) . The rationale for using this method was that the experiences of mothers of VLBWIs regarding DHM represent a process-oriented phenomenon. Furthermore, as the study focuses on mothers who are expressing their own milk while using DHM, and their experiences evolve through interactions with their infants, family members, and healthcare professionals, a perspective of social interaction is essential. Therefore, M-GTA was considered appropriate for this study, whose analytical focus was ‘mothers of VLBWIs who had progressed well after birth’. The analytical theme was defined as ‘the process through which mothers using DHM for the first time come to reconcile their sentiments’. Interviews were audio-recorded and transcribed verbatim. To ensure the credibility of the analysis, the analysis was conducted under the guidance of a supervisor experienced in the M-GTA methodology.The specific analytical procedures were as follows: Interviews conducted with participants using the interview guide were transcribed verbatim and thoroughly reviewed. The transcript containing the richest content relevant to the analytical theme was selected as the initial data for analysis. Using an analytical worksheet, the selected transcript was examined in relation to the analytical focus and theme. Sections most relevant to the theme were identified as initial exemplars, definitions were assigned, and concepts were generated. Subsequently, additional exemplars from other sections of the transcripts were compared with the initial definitions and concept names and added to the variation column. Through constant comparative analysis, new concepts were generated while analysing the data. For each concept, a new analytical worksheet was created, and similarities and opposites were also examined. After the final data analysis, it was confirmed that no new concepts were emerging, categories were generated, and theoretical saturation was determined. Relationships among the categories were examined, and a result diagram and storyline were developed. Results Sample Characteristics All 10 participants were Japanese, married, using DHM for the first time, and aged 27–39 years (mean 34 years, standard deviation [SD] 4.3 years), They had all intended to breastfeed their infants with their own milk whenever possible, ideally exclusively. Four were primiparous, and six were multiparous, with two multiparous participants having twins. Overall, they had no physical or mental health issues. Gestational ages at birth ranged from 23 weeks and 4 days to 30 weeks and 3 days (mean 27 weeks and 3 days, SD 2 weeks and 3 days). At the time of the interviews, all participants were using DHM. Interviews were conducted between one and four months postpartum (mean 48 days). Participants’ demographic and clinical characteristics are presented in Table 1. Table 1. Participant characteristics The analysis yielded 17 concepts, 7 subcategories, and one core category. Data saturation was confirmed after the tenth interview. Figure 1 illustrates the relationships among the categories and the overall process identified in this study. Storyline Mothers using DHM for the first time expressed a strong desire for【 Bonding through mother ’ s own milk 】yet giving birth to a very low birth weight infant created a conflict between【 Prioritize the child's life 】 and experiencing【 Anxiety about using DHM 】 , reflecting a 『 Conflict between genuine sentiment and reality 』 . However, through 【 Words from those who stay beside the mother 】 , mothers chose to use DHM. During the prolonged period of milk expression, they experienced 【 Loneliness of being apart from the Infant 】 , but 【 Words from those who stay beside the mother 】 also helped them gain 【 Recognizing the role of DHM 】 . As a result, while some internal conflict remained, mothers reaffirmed the value of their own milk and came to 【 Reconciliation through expressing milk and the infant ’ s growth 】 . Categories and Concepts The meanings and illustrative examples of the categories and concepts are presented as follows. In the following text, core categories are enclosed in 『 』, categories in 【 】, concepts in ＜＞, and narratives are separated into independent paragraphs. Supplementary explanations are indicated in ( ). Core Category : 『 Conflict between genuine sentiment and reality 』 It is composed of 7 subcategories, that have been described in detail in the following sections. Category 1 : 【 Prioritise the Child’s Life 】 It reflects mothers’ understanding, based on physicians’ explanations of the potential adverse effects of formula feeding on VLBWIs, and their recognition that DHM serves as a substitute when their own milk production is insufficient, ultimately contributing to their infants’ survival. It is composed of two concepts: Concept 1 : This concept underscores that understanding the adverse effects of formula feeding allows mothers to reaffirm the benefits of providing their own breast milk to their infants, thereby supporting their decision to use DHM as one of the options. When I first heard that giving formula might cause intestinal perforation, I thought, “How wonderful breast milk is!” Considering that the number of births is decreasing and fewer mothers are able to provide their own milk, I felt deeply grateful that there are mothers willing to give breast milk. Without them, this infant might not have grown as well. Thanks to this system, some infants are able to grow and thrive. （I） Concept 2 : This concept underscores that in the context of critical care for infants, mothers can feel gratitude for DHM, as it has the potential to save their child’s life, even though it is someone else’s milk. I did not hesitate to use DHM. From the beginning, I thought that if it was better for my child than formula, even a little, that was what mattered. My own feelings were secondary; what was important was doing what was best for my child. I had no negative impressions initially, and I have felt grateful for it from the start, without any change in that perception.（C） Category 2 : 【 Bonding through mother’s own milk 】 It reflects mothers’ desire to nurture their infants with their own breast milk, ideally without using DHM. However, given the reality that their own milk production is insufficient immediately after birth, mothers wish to provide at least the first feed with their own milk for establishing a bond with their child. It is composed of three concepts: Concept 1 : This concept underscores mothers’ desire to feed their infants with their own breast milk, however, they face a reality where their own milk production is insufficient immediately after birth. If my milk had come in, of course, I would have wanted to feed my infant with my own breast milk from the very beginning. (G) Concept 2 : This concept underscores that mothers wish to establish a bond with their infant by providing at least the first feed with their own milk, reflecting both their desire and the infant’s needs. What does it mean… hmm… well, I think it comes from the desire for my child to grow and develop. I also feel a sense of connection, though the child may not understand my feelings—it might just be my own ego, haha. (F) Concept 3 : This concept underscores that mothers wish to provide at least the first feed to their infants with their own milk, reflecting their desire and intention. During hospitalisation, when my expressed milk was collected and I saw it glisten, the midwife encouraged me to let the infant have it, saying, “Please let them take it in their mouth”. At that moment, I felt very happy, and I realised that in my heart I had always wanted the first feed to be my own breast milk.（I） Category 3 : 【 Anxiety about using DHM 】 It reflects that mothers face a situation, where they must choose DHM because their own milk production is insufficient for their infant, which is directly linked to the infant’s survival. Simultaneously, using DHM raises various concerns because it is someone else’s milk. It is composed of two concepts: Concept 1 : ＜ We have no choice but to select it as a ‘ stopgap measure ’ ＞ This concept underscores that mothers face an inevitable situation where they must choose DHM because the insufficient production of their own milk is directly linked to their infant’s survival. So, I said, “Please go ahead”. It felt as if there were no real choice. I was told that DHM is better for digestion than formula, and I thought, “Well, then I’ll go with DHM”,—there really wasn’t an alternative. (C) Concept 2 : This concept underscores that mothers experience anxiety regarding DHM due to its providers’ uncertain lifestyle characteristics. Well, if it is my own milk, I know, at least to some extent, what has gone into it—for example, the food I ate yesterday becomes part of my blood and then my milk, even if it is far from perfect. But with someone else’s breast milk, I cannot know these details. (D) Category 4 : 【 Words from those who stay beside the mother 】 It describes the process by which mothers move forward in accepting and reconciling with the use of DHM through trusted individuals’ supportive words, and is composed of four concepts: Concept 1 : This concept underscores that positive words from the husband, who is a life partner in child-rearing, guides and supports the mother in choosing to use DHM. Yes, I think I probably could not have made the decision on my own. It started with wondering, “What exactly is donor human milk?” I also found myself thinking about what kind of person the donor was, and what the milk might be like. My husband’s positive attitude, however, helped me feel that it was okay and supported me in making the decision. (F) Concept 2 : This concept underscores that, in situations where mothers must rely on others instead of their own breast milk, positive words from someone with a maternal experience, with whom they can share and relate, serve as a source of support. Ah, yes. I talked with my mother and friends, and they said that since it is breast milk, it is easier to digest, and if it can be borrowed, it is something to be grateful for. Hearing these words gradually gave me a positive perspective and I think they helped me approach the situation with a forward-looking mindset.(H) Concept 3 : This concept underscores that mothers trust their husbands, who unconditionally prioritise the well-being of both mother and infant, and are able to accept and be reassured by their supportive words. Well, I think the decision was probably not wrong. He considered not only the child, but also me, when making the decision, and that left me with no sense of anxiety. (B) Concept 4 : This concept underscores that words from physicians and nurses involved in their infant’s daily care and growth, serve as triggers for mothers to come to terms with using DHM. Yes, the staff informed me about how much milk my child was consuming, and how well the milk was being digested. They also provided updates on the child’s weight.Seeing how much my child has grown made me feel very positive. Overall, I have no concerns and feel grateful for their attentive care as my child is thriving. (D) Category 5 : 【 Loneliness of Being Apart from the Infant 】 It describes how prolonged periods of expressing breast milk while the infant is not physically present can lead mothers to experience feelings of loneliness, and cause fluctuations in perceptions of their maternal role. It is composed of two concepts: Concept 1 : This concept underscores that expressing breast milk in the infant’s absence evokes a sense of loneliness and feeling of futility owing to the immediate lack of reward. Yes, I do have the desire to deliver the expressed milk, at least in thought, but I feel that I’m not fully motivated from the bottom of my heart. The pure intention of “I must deliver it” seems to have faded, and it feels somewhat mechanical, like a routine task. (A) Concept 2 : This concept refers to the phenomenon, in which, insufficiency of mother’s own milk challenges or destabilises her perception of her ideal maternal self. Honestly, at first I thought, “Oh, donor milk… so my baby is drinking another mother’s milk…” I felt a strong sense of disappointment and guilt, as if I couldn’t provide it myself. Not blaming myself per se, but I felt sorry. (J） Category 6 : 【 Recognising the role of DHM 】 It represents the realisation that when mother’s own milk is insufficient, the availability of DHM provides reassurance, given that, despite being another person’s milk, it serves the same purpose of supporting the infant’s healthy growth. It is composed of two concepts: Concept 1 : This concept underscores that mothers feel reassured knowing that DHM can support their infant’s growth in alignment with their own maternal intentions, serving as a supplement when their own milk production is insufficient. I feel that everything will be all right as long as my baby can grow with breast milk, even if it is from another mother. What matters most is that my baby grows healthy. If I had to rely solely on my own milk, I would probably feel pressured and exhausted. But knowing that DHM is available gives me a sense of relief — it provides emotional comfort and peace of mind. (D) Concept 2 : This concept underscores the perception that DHM is equivalent to maternal breast milk in sustaining an infant’s life. Mothers expressed reassurance in recognising that, although the milk comes from another person, it serves the same purpose of supporting their infant’s survival and healthy growth. Well, there was no one around me who had used it before; so, I did not have any prior experience or information. However, with formula, there can be compatibility issues, and I was not sure if it could meet the needs of a preterm infant. In contrast, I perceive breast milk as inherently beneficial, and therefore I considered DHM to be very good. (H) Category 7 : 【 Reconciliation through expressing milk and the infant ’ s growth 】 It represents how mothers reconcile their experiences by recognising the benefits of breast milk. Such recognition enhances their motivation to continue breastfeeding through milk expression, and allows them to appreciate their infants’ steady growth despite lingering internal conflict. It comprises two concepts: Concept 1 : This concept underscores that because of using DHM, mothers observe their infants’ healthy growth and recognise the benefits of breast milk, which in turn, motivates them to continue breastfeeding. Well, I do think mother’s own milk is special. Although I used donor milk, I still wanted to give my own milk as much as possible. I was told it helps with immunity, and seeing that made me feel it’s important. So, I want to continue breastfeeding. (F) Concept 2 : This concept underscores that, although mothers retain some emotional ambivalence, they experience gratitude for their infant’s healthy growth, facilitated by the use of DHM. The complex feelings towards donor human milk decrease somewhat as the infant grows—not entirely, but the mother feels grateful for the support of the donor, recognising that the milk contributed to her child’s wellbeing. (B) Discussion This study employed semi-structured interviews and analysed the data using M-GTA, which yielded one core category and seven subcategories. Based on this study’s results, three key points are discussed. First, mothers experience a 『Conflict between genuine sentiment and reality』 wherein their genuine desire relating to 【 Bonding through mother’s own milk】 coexists with the necessity to 【Prioritise the child's life】 and 【Anxiety about using DHM】 . Second, mothers reconcile their experiences through the influence of 【Words from those who stay beside the mother】 and achieve a balance between 【Reconciliation through expressing milk and the infant’s growth】. Third, 【Words from those who stay beside the mother】 provided insights for clinical nursing practice. The mothers’『Conflict between genuine sentiment and reality』 The mothers expressed that giving birth to an ELBWI led them to grapple with their situation’s reality, while simultaneously holding a genuine desire for 【Bonding through mother’s own milk】 . During gestation, mothers and their infants are connected via the placenta and umbilical cord, creating a unified mother–infant dyad. However, birth physically separates mothers from their infants. For mothers of preterm infants, in particular, breastfeeding serves as a means of reconstructing the maternal–infant bond, and represents an act that only the mother can provide for her child 13) . This maternal desire may be reflected in expressing breast milk to the infant, which could serve as a means of re-establishing connection with the separated newborn. For mothers who have given birth to preterm infants requiring NICU hospitalisation, breastfeeding represents the only act that only they can do for their babies 14) . Therefore, to establish a bond with the child, it may be necessary that , rather than DHM. Breast milk protects preterm infants from complications such as NEC 15) . This is equivalent to sustaining the infant’s life, and stabilising the infant’s condition can alleviate maternal guilt associated with preterm birth 14) . This desire is about establishing an emotional bond with the infant, and reflects the mother’s earnest wish for her baby’s healthy growth. It may be linked to the mother’s , as a way of conveying that heartfelt wish to feed her child. Fulfilling this desire is essential for supporting mothers in accomplishing their maternal role. 【Words from those who stay beside the mother】 and【 Reconciliation through expressing milk and the infant’s growth】 Preterm infants’ birth often occurs as an emergency, and during hospitalisation, explanations are primarily directed to the father. When prior information regarding DHM has not been provided, fathers frequently receive explanations about DHM, alongside updates on the infant’s condition. However, as breast milk is a highly sensitive matter, it is essential to respect the mother’s feelings. This study’s findings indicate that mothers decide to use DHM with the support and presence of attentive husbands, and trusted experienced mothers. Subsequently, through interactions with their husbands who cherish them and their child, trusted experienced mothers, and guidance from doctors and nurses, mothers recognise the importance of breast milk and observe their infants’ growth. This process enables them to reconcile their conflicting feelings regarding the use of DHM. When a mother must make a decision, such as whether to use DHM, or when she feels uncertain or lost, support from close family members is crucial. Mothers seek approval and support from their families even during pregnancy 16) . Previous studies have reported that a mother’s primary sources of information are her husband/partner, and/or her own mother 17) . Among these, support from the husband/partner is particularly important, as it bolsters the mother’s confidence 17) . Providing mothers with specific information from healthcare professionals about their infant’s condition and associated care promotes maternal well-being, and influences caregiving practices 18) . In cases of preterm birth, mothers often experience guilt about delivering a small infant, and stress from being unable to engage in typical caregiving. Therefore, encouraging maternal contact, participating in care, and breastfeeding fosters bonding and enhances maternal satisfaction 19) . In sum, healthcare professionals need to inform mothers about their infant’s growth and condition while using DHM, to support breastfeeding, and facilitate maternal participation in care to the extent possible. Furthermore, the findings reveal a positive outlook , along with expressing gratitude for the infant’s growth despite lingering ambivalence—that is,—enables mothers to reconcile the『Conflict between genuine sentiment and reality』. As DHM is another person’s milk, mothers may experience barriers, such as fear of infection, aversion to another person’s bodily fluids, and concerns regarding bonding 20) . Nevertheless, by providing their own breast milk to their infants and simultaneously recognising its benefits, mothers can also develop gratitude towards DHM 21) . To provide appropriate support, healthcare professionals need to understand the impact of breast milk on mother–infant dyads. Importantly, the significance of a mother’s own milk for mothers of preterm infants, who through caring for their child and wishing for their health, can deepen attachment, enhance maternal confidence, and accept their situation 22) . This may also contribute to the mother’s understanding that given the importance of breast milk, supplementing DHM with her own milk is essential. Furthermore, as previous research has indicated, mothers of preterm infants are deeply concerned about their child’s health 22) . Sharing information about their infants’ growth can be considered a factor that facilitates the mother’s process of reconciling conflicting feelings. Therefore, healthcare professionals should provide breastfeeding support while clearly communicating the infant’s condition to the mother and actively facilitating her participation in care. Clinical Implications for Nursing from the Category of 【Words from those who stay beside the mother】 Family relationships play a crucial role in helping mothers using DHM to accept and reconcile with it. Midwives need to understand these relationships, and provide care that involves and supports the family as a whole. This study’s participants had supportive families; however, in recent years, family structures have become more diverse, including nuclear families and single-parent households. Some mothers may lack immediate familial support; therefore, healthcare professionals’ role is particularly significant. Facilitating connections among mothers who have given birth to preterm infants and used DHM, and providing opportunities for group gatherings, is important. Additionally, prenatal education should provide all expectant mothers and parents with knowledge about preterm birth, emphasising the importance of preparation and awareness before delivery. Prenatal education equips mothers to better cope with unexpected situations; hence, preparing and educating mothers is considered the responsibility of healthcare professionals 23) . Healthcare professionals themselves were also perceived as those who【from those who stay beside the mother】.Mothers of preterm infants often experience compounded stress, including guilt related to preterm birth and emotional ambivalence regarding DHM use. Prolonged separation in many cases can place a significant burden on parents, who have lost confidence in their parental role 24) . Long-term physical separation between mother and infant has also been reported to induce maternal stress, anxiety, and depression 25) , which may, in turn, affect preterm infants’ future development. From an early stage, healthcare professionals need to recognise that mothers—and their partners—may wish to provide mother’s breast milk, while also thoroughly explaining the following: benefits of breast milk, that DHM is intended for use only when maternal milk is insufficient, and the potential influence of donor-related factors, such as infectious diseases, genetics, lifestyle, and health status on milk quality. When mothers receive such comprehensive explanations, they are able to provide informed consent for using DHM 26) . Providing breast milk is an activity that makes a mother feel indispensable 13) . This process allows mothers to feel connected to their children and support their health, thereby fostering a sense of well-being. Simultaneously, it partially mitigates the sadness associated with the physical separation from the infant 27)28) . Finally, recognising that mothers have a strong desire to know about their preterm infants’ condition 18) , and pray for their health 22) , healthcare professionals should provide them with daily updates on their child’s growth. Observing their infants’ growth allows mothers to feel that choosing DHM, primarily to protect the child from complications, was the correct decision 26) . Continued breastfeeding, combined with monitoring the child’s development, contributes to the process by which mothers reconcile their 『Conflict between genuine sentiment and reality』 regarding the use of donor human milk (DHM). Furthermore, sustained breastfeeding plays a crucial role in strengthening maternal confidence, fostering mother–infant bonding, and supporting the infant’s optimal growth and health. One possible explanation is that staff education and the provision of consistent breastfeeding information to families promote mothers’ acceptance of DHM as a temporary bridge, which may lead to higher rates of mothers subsequently providing their own milk. Indeed, Delfosse et al reported that, following staff training and unified breastfeeding support, more than 80% of mothers ultimately provided their own milk to their infants 29) . This study has several limitations. It was conducted within a Japanese cultural context and included only 10 mother–infant dyads with favourable prognoses. Consequently, all the participants were in situations where they could receive support from their families. If family consent or support is unavailable, the process by which mothers come to terms with using DHM may differ. Furthermore, as it focused exclusively on mothers, fathers’ perspectives and evolving experiences on DHM were not explored. Hence, future research should explore them, both in their own right and in their role as supporting partners, to examine how each parent’s feelings interact with one another. Conclusion The process by which mothers of ELBWIs reconcile their feelings when using DHM for the first time was elucidated by identifying 17 concepts, seven subcategories, and one core category. Although mothers experienced a『Conflict between genuine sentiment and reality』regarding the use of DHM, support through 【Words from those who stay beside the mother】enabled them to decide to use DHM and achieve【Reconciliation through expressing milk and the infant’s growth】. These findings underscore the importance of providing all expectant parents with prenatal breastfeeding education that includes information about preterm birth and DHM. Moreover, healthcare professionals supporting mothers of preterm infants using DHM should understand this psychological process, and recognise their own role in offering【Words from those who stay beside the mother】, and thereby provide effective support. Abbreviations VLBWIs: very low birth weight infants DHM: donor human milk NEC: necrotising enterocolitis NICUs: neonatal intensive care units Declarations Ethics approval and consent to participate This study was approved by the Nara Medical University Ethics Committee (approval no. 3885). Written informed consent was obtained from all participants. There was no remuneration for involvement. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing interests The authors declare that they have no competing interests. Authors' contributions MM designed the study, conducted the interviews, analysed the data, prepared the figures and tables, and drafted the manuscript. YT provided an explanation of the study to the patient and obtained preliminary consent. YU supervised the study. TI supervised the study, supported data analysis and the preparation of figures and tables, and edited the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors sincerely thank the mothers who participated in this study. We also thank Prof. Kumiko Kotake (Department of Home Nursing, Nara Medical University) and Prof. Koji Yamazaki (Graduate School of Health and Social Sciences, Shizuoka University) for their valuable guidance. References United Nations Children’s Fund (UNICEF). The State of the World’s Children 2024: Statistical Compendium. New York (NY): UNICEF; 2024. Available from:https://data.unicef.org/resources/sowc-2024/ Ministry of Health, Labour and Welfare (JP). Live births and percentage distribution according to birth weight and mean birth weight, 1975–2019 [Internet]. Tokyo: Ministry of Health, Labour and Welfare; 2021 [cited 2025 Sep 8]. Available from: https://www.mhlw.go.jp/english/database/db-hw/FY2021/dl/live_births03.pdf Sato M, Hamada Y, Kohno M, Ise K, Uchida K, Ogata H, et al. Neonatal gastrointestinal perforation in Japan: a nationwide survey. Pediatr Surg Int. 2017;33(1):33-41. Epub 20160930. doi: 10.1007/s00383-016-3985-z. PubMed PMID: 27696212. Quigley M, Embleton ND, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2019;7(7):Cd002971. Epub 20190719. doi: 10.1002/14651858.CD002971.pub5. PubMed PMID: 31322731; PubMed Central PMCID: PMC6640412. Miller J, Tonkin E, Damarell RA, McPhee AJ, Suganuma M, Suganuma H, et al. A Systematic Review and Meta-Analysis of Human Milk Feeding and Morbidity in Very Low Birth Weight Infants. Nutrients. 2018;10(6). Epub 20180531. doi: 10.3390/nu10060707. PubMed PMID: 29857555; PubMed Central PMCID: PMC6024377. Belfort MB, Anderson PJ, Nowak VA, Lee KJ, Molesworth C, Thompson DK, et al. Breast Milk Feeding, Brain Development, and Neurocognitive Outcomes: A 7-Year Longitudinal Study in Infants Born at Less Than 30 Weeks' Gestation. J Pediatr. 2016;177:133-9.e1. Epub 20160729. doi: 10.1016/j.jpeds.2016.06.045. PubMed PMID: 27480198; PubMed Central PMCID: PMC5037020. Mӧrelius E, Kling K, Haraldsson E, Alehagen S. You can't flight, you need to fight-A qualitative study of mothers' experiences of feeding extremely preterm infants. J Clin Nurs. 2020;29(13-14):2420-8. Epub 20200413. doi: 10.1111/jocn.15254. PubMed PMID: 32223034. Alves E, Magano R, Amorim M, Nogueira C, Silva S. Factors Influencing Parent Reports of Facilitators and Barriers to Human Milk Supply in Neonatal Intensive Care Units. J Hum Lact. 2016;32(4):695-703. Epub 20160926. doi: 10.1177/0890334416664071. PubMed PMID: 27563012. Iida M, Horiuchi S, Nagamori K. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth. 2014;27(3):202-7. Epub 20140603. doi: 10.1016/j.wombi.2014.05.001. PubMed PMID: 24906495. Mizuno K, Shimizu T, Ida S, Ito S, Inokuchi M, Ohura T, et al. Policy statement of enteral nutrition for preterm and very low birthweight infants. Pediatr Int. 62. Australia: © 2020 The Authors. Pediatrics International published by John Wiley & Sons Australia, Ltd on behalf of Japan Pediatric Society.; 2020. p. 124-7. Oshima N, Kikuchi A. A qualitative study of mothers’ experiences with donor human milk. J Jpn Soc Breastfeed Res. 2024;18(1):23-30. Modified Grounded Theory Approach Research Group. What is M-GTA? [Internet]. Japan: M-GTA Research Group; [cited 2026 Feb 4]. Available from: https://m-gta.jp/en/ Ikonen R, Paavilainen E, Kaunonen M. Preterm Infants' Mothers' Experiences With Milk Expression and Breastfeeding: An Integrative Review. Adv Neonatal Care. 2015;15(6):394-406. doi: 10.1097/anc.0000000000000232. PubMed PMID: 26536173. Rossman B, Kratovil AL, Greene MM, Engstrom JL, Meier PP. "I have faith in my milk": the meaning of milk for mothers of very low birth weight infants hospitalized in the neonatal intensive care unit. J Hum Lact. 2013;29(3):359-65. Epub 20130418. doi: 10.1177/0890334413484552. PubMed PMID: 23599267. Perrin MT, Mansen K, Israel-Ballard K, Richter S, Bode L, Hampel D, et al. Investigating donor human milk composition globally to develop effective strategies for the nutritional care of preterm infants: Study protocol. PLoS One. 2023;18(4):e0283846. Epub 20230405. doi: 10.1371/journal.pone.0283846. PubMed PMID: 37018290; PubMed Central PMCID: PMC10075430. Mercer RT. Nursing support of the process of becoming a mother. J Obstet Gynecol Neonatal Nurs. 2006;35(5):649-51. doi: 10.1111/j.1552-6909.2006.00086.x. PubMed PMID: 16958722. Leahy Warren P. First-time mothers: social support and confidence in infant care. J Adv Nurs. 2005;50(5):479-88. doi: 10.1111/j.1365-2648.2005.03425.x. PubMed PMID: 15882364. Lupton D, Fenwick J. 'They've forgotten that I'm the mum': constructing and practising motherhood in special care nurseries. Soc Sci Med. 2001;53(8):1011-21. doi: 10.1016/s0277-9536(00)00396-8. PubMed PMID: 11556771. Bertino E, Giuliani F, Baricco M, Di Nicola P, Peila C, Vassia C, et al. Benefits of donor milk in the feeding of preterm infants. Early Hum Dev. 2013;89 Suppl 2:S3-6. Epub 20130806. doi: 10.1016/j.earlhumdev.2013.07.008. PubMed PMID: 23932110. Coutsoudis I, Petrites A, Coutsoudis A. Acceptability of donated breast milk in a resource limited South African setting. Int Breastfeed J. 2011;6:3. Epub 20110222. doi: 10.1186/1746-4358-6-3. PubMed PMID: 21342496; PubMed Central PMCID: PMC3049132. Loh HF, Lee JR, Tan AR, Goh XL, Low YF, Ng YPM, et al. Emotional journey of Asian mothers of premature infants who received pasteurised donor human milk: a qualitative study. Arch Dis Child Fetal Neonatal Ed. 2023;108(4):348-53. Epub 20221223. doi: 10.1136/archdischild-2022-324748. PubMed PMID: 36564162. Sih DA, Bimerew M, Modeste RRM. Coping strategies of mothers with preterm babies admitted in a public hospital in Cape Town. Curationis. 2019;42(1):e1-e8. Epub 20191001. doi: 10.4102/curationis.v42i1.1872. PubMed PMID: 31590568; PubMed Central PMCID: PMC6779964. Gebre M, Gebremariam A, Abebe TA. Birth Preparedness and Complication Readiness among Pregnant Women in Duguna Fango District, Wolayta Zone, Ethiopia. PLoS One. 2015;10(9):e0137570. Epub 20150917. doi: 10.1371/journal.pone.0137570. PubMed PMID: 26379231; PubMed Central PMCID: PMC4574761. Jackson K, Ternestedt BM, Schollin J. From alienation to familiarity: experiences of mothers and fathers of preterm infants. J Adv Nurs. 2003;43(2):120-9. doi: 10.1046/j.1365-2648.2003.02686.x. PubMed PMID: 12834369. Miles MS, Holditch-Davis D, Schwartz TA, Scher M. Depressive symptoms in mothers of prematurely born infants. J Dev Behav Pediatr. 2007;28(1):36-44. doi: 10.1097/01.DBP.0000257517.52459.7a. PubMed PMID: 17353730. Esquerra-Zwiers A, Rossman B, Meier P, Engstrom J, Janes J, Patel A. "It's Somebody Else's Milk": Unraveling the Tension in Mothers of Preterm Infants Who Provide Consent for Pasteurized Donor Human Milk. J Hum Lact. 2016;32(1):95-102. Epub 20151120. doi: 10.1177/0890334415617939. PubMed PMID: 26590179; PubMed Central PMCID: PMC4959541. Sweet L. Birth of a very low birth weight preterm infant and the intention to breastfeed 'naturally'. Women Birth. 2008;21(1):13-20. Epub 20071226. doi: 10.1016/j.wombi.2007.11.001. PubMed PMID: 18162451. Sweet L. Expressed breast milk as 'connection' and its influence on the construction of 'motherhood' for mothers of preterm infants: a qualitative study. Int Breastfeed J. 2008;3:30. Epub 20081217. doi: 10.1186/1746-4358-3-30. PubMed PMID: 19091075; PubMed Central PMCID: PMC2628335. Delfosse NM, Ward L, Lagomarcino AJ, Auer C, Smith C, Meinzen-Derr J, et al. Donor human milk largely replaces formula-feeding of preterm infants in two urban hospitals. J Perinatol. 2013;33(6):446-51. Epub 20121220. doi: 10.1038/jp.2012.153. PubMed PMID: 23258498; PubMed Central PMCID: PMC3810409. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 May, 2026 Reviews received at journal 08 May, 2026 Reviewers agreed at journal 02 May, 2026 Reviews received at journal 22 Mar, 2026 Reviewers agreed at journal 20 Mar, 2026 Reviewers invited by journal 18 Mar, 2026 Editor assigned by journal 27 Feb, 2026 Submission checks completed at journal 27 Feb, 2026 First submitted to journal 16 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8890909","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610125368,"identity":"529047f1-82c1-470d-9e7b-177df1a84a7e","order_by":0,"name":"Miwa Magomoto","email":"","orcid":"","institution":"Nara Medical University","correspondingAuthor":false,"prefix":"","firstName":"Miwa","middleName":"","lastName":"Magomoto","suffix":""},{"id":610125369,"identity":"b95b89f5-d8a1-453c-9912-d7a97a0328cc","order_by":1,"name":"Yuki Tani","email":"","orcid":"","institution":"Nara Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuki","middleName":"","lastName":"Tani","suffix":""},{"id":610125370,"identity":"d40006e7-3fb4-472d-a17b-64316e61efcb","order_by":2,"name":"Yumiko Uchida","email":"","orcid":"","institution":"Nara Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yumiko","middleName":"","lastName":"Uchida","suffix":""},{"id":610125371,"identity":"9da9c9fa-bc3c-41f6-91fb-2ea723634ace","order_by":3,"name":"Toshiko Igarashi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYBACNgh1gIcfKsDYgCKBT4tkA7FaoOAAg8EBVC24AR//4mcffvy5I2N8u/nZh585NrINEgmMH34w8OXhdJjEM+OZvW3PeMzuHAMytqUZA7UwS/YwsBXj1nLAmIG34TCP2Y0EIGPb4cT9NxIYpIESibhcyCZx/DPjnz+HeYxnpH9m/LvtfyLIlt94tfD3GDPzsB3mMZDIMWbm3XYApIWNgC08xcyybYd5JG7kABnbko0beB62WfYY4PaLfP/xzYxv/hy255+Rvpnx7TY72Qb25MM3flQcwxliDBIJGEKgqDE4hikOA/wHsIvX4NYyCkbBKBgFIw0AAPHRVMx9X+GOAAAAAElFTkSuQmCC","orcid":"","institution":"Nara Medical University","correspondingAuthor":true,"prefix":"","firstName":"Toshiko","middleName":"","lastName":"Igarashi","suffix":""}],"badges":[],"createdAt":"2026-02-16 07:53:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8890909/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8890909/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105282451,"identity":"4031e763-9399-42ae-80fc-b8f0ca746926","added_by":"auto","created_at":"2026-03-24 10:28:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":188809,"visible":true,"origin":"","legend":"\u003cp\u003eMothers’ Reconciliation Process Regarding DHM Use\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8890909/v1/e510b1f44b43fc05c3bb0015.png"},{"id":105564769,"identity":"61a4d769-2f7f-47a4-8063-16ac815383aa","added_by":"auto","created_at":"2026-03-27 12:50:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1731455,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8890909/v1/474646a6-1a96-4c23-8f43-1cbbf1374bcd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Japanese Mothers’ Experiences and Sentiments Towards Donor Human Milk for Very Low Birth Weight Infants: A Modified Grounded Theory Approach","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccording to \u003cem\u003eUNICEF\u0026rsquo;s State of the World\u0026rsquo;s Children 2024\u003c/em\u003e, the global average neonatal mortality rate is 1.7%, whereas Japan reports a rate of 0.1% of live births, reflecting substantial advances in perinatal and neonatal care\u003csup\u003e1)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e Advances in medical care have led to Japan\u0026rsquo;s low neonatal mortality rate, indicating that it has one of the safest and most advanced healthcare systems worldwide. However, its proportion of very low birth weight infants (VLBWIs) has been increasing. Between 1980 and 2019, the proportion of VLBWIs (\u0026lt;\u0026thinsp;1,500 g) increased from 0.3% to 0.7%, while that of extremely low birth weight infants (ELBWIs) (\u0026lt;\u0026thinsp;1,000 g) also rose from 0.1% to 0.3%\u003csup\u003e2)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eInfants admitted to neonatal intensive care units (NICUs) are mainly preterm or with low birth weight, immature immune systems, and a high risk of developing complications, such as necrotising enterocolitis (NEC). Sato et al. reported that the mortality rate of NEC with intestinal perforation among infants in NICUs reached 58%\u003csup\u003e3)\u003c/sup\u003e. Furthermore, Quigley et al. indicated that formula feeding increased the mortality risk associated with intestinal necrosis by 1.87 times\u003csup\u003e4)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn NICU infants, breast milk serves as a source of nutrition and plays a vital role in preventing complications. A higher proportion of human milk in enteral feeding has been associated with lower incidences of NEC, bronchopulmonary dysplasia, retinopathy of prematurity, and late-onset sepsis \u003csup\u003e5)\u003c/sup\u003e. Moreover, breast milk has been shown to improve long-term cognitive and motor development\u003csup\u003e6)\u003c/sup\u003e. Recognising its benefits, mothers initiate milk expression for their infants. Conversely, regardless of their infants\u0026rsquo; health condition, mothers strongly desire to breastfeed, perceiving it as a \u0026lsquo;natural\u0026rsquo; act and an essential \u0026lsquo;maternal role\u0026rsquo; that they are expected to perform\u003csup\u003e7)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, due to factors such as mother\u0026ndash;infant separation, stress, and underdeveloped mammary glands resulting from premature birth, mothers may experience difficulties producing sufficient breast milk in the early stage\u003csup\u003e8)\u003c/sup\u003e. Therefore, the World Health Organisation recommends using donor human milk (DHM) to prevent life-threatening NEC\u003csup\u003e9)\u003c/sup\u003e. To ensure that mothers\u0026rsquo; own milk can be provided immediately, Japan has also made DHM available as a temporary substitute by establishing human milk banks in 2017\u003csup\u003e10)\u003c/sup\u003e. Although several studies have examined DHM\u0026rsquo;s effects and composition, research focusing on the experiences and feelings of mothers using DHM remains limited. Previous studies have shown that mothers wish to be the sole providers of breast milk for their infants, and they may experience anxiety or reluctance about giving DHM because of infants\u0026rsquo; health concerns\u003csup\u003e11)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, mothers\u0026rsquo; feelings after childbirth are dynamic and fluctuate based on interactions with those around them. Therefore, their perceptions of DHM may also change through these interactions.\u003c/p\u003e \u003cp\u003eAs human milk banks are being established in an increasing number of countries, particularly in regions where DHM has been introduced relatively recently, understanding mothers\u0026rsquo; emotional and relational experiences during this early implementation phase is crucial. Cultural expectations regarding breastfeeding and maternal roles may influence how mothers interpret the use of DHM, yet little is known about these processes in newly adopting contexts.\u003c/p\u003e \u003cp\u003eThis study aimed to clarify the process through which mothers with infants in NICUs, who decided to use DHM while expressing their own milk, experienced and developed their thoughts and emotions regarding their infants and social interactions, to identify implications for nursing support.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003eStudy\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study employed semi-structured interviews and was analysed using the Modified Grounded Theory Approach (M-GTA) to explore process-oriented maternal experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a single-site study at a 21-bed Japanese university hospital\u0026rsquo;s NICU, providing specialised care for VLBWIs, following standard DHM protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThey comprised mothers: 1) whose infants met the eligibility criteria outlined in the Japanese guidelines for initiating DHM use\u0026mdash;birth weight \u0026lt;1,500 g or a gestational age of \u0026lt;32 weeks; 2) who had initiated milk expression and were using DHM for the first time; 3) whose infants were hospitalised in the NICU; 4) who had completed 2\u0026ndash;3 weeks since birth and both mother and infant were clinically stable; 5) who had established a positive attachment to their infants and provided informed consent to participate in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExclusion criteria comprised mothers: 1) with comorbid psychiatric disorders, difficulty communicating with the researcher, poor acceptance of the infant, and lack of breast milk; 2) whose infants received DHM due to underlying medical conditions, and had chromosomal or genetic abnormalities, unstable conditions, or poor prognosis; and 3) who did not provide informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Nara Medical University Ethics Committee (approval no. 3885) on November 1, 2024. Written informed consent was obtained from all participants prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCollection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative data were collected through interviews conducted between November 2024 and August 2025. Potential participants were recruited by the principal investigator\u0026mdash;a midwife working in the NICU\u0026mdash;and co-investigators based on the inclusion and exclusion criteria. To avoid any sense of coercion, the co-investigators first obtained preliminary consent from participants. Care was taken to\u0026nbsp;ensure\u0026nbsp;participants understood that participation\u0026nbsp;was entirely voluntary. Specifically, the study information sheet\u0026nbsp;clearly explained\u0026nbsp;that non-participation would not affect\u0026nbsp;their infants\u0026rsquo;\u0026nbsp;treatment or nursing care in any way, and that\u0026nbsp;they\u0026nbsp;could withdraw at any time,\u0026nbsp;even after\u0026nbsp;giving preliminary consent.\u0026nbsp;Thereafter, participants\u0026rsquo;\u0026nbsp;written informed consent was obtained, and\u0026nbsp;they\u0026nbsp;were asked about their prenatal intentions regarding breastfeeding and their current milk expression status, using a\u0026nbsp;data collection sheet.\u0026nbsp;Subsequently, semi-structured interviews lasting approximately 30\u0026ndash;60 minutes were conducted using an interview guide developed specifically for this study. The interviews explored mothers\u0026rsquo; experiences and perceptions, including support for continuing milk expression, their initial reactions upon learning about DHM,\u0026nbsp;their\u0026nbsp;decision to use DHM,\u0026nbsp;their\u0026nbsp;current feelings\u0026nbsp;towards\u0026nbsp;DHM,\u0026nbsp;their\u0026nbsp;thoughts regarding their role as\u0026nbsp;mothers\u0026nbsp;and their\u0026nbsp;infants\u0026nbsp;while continuing to express milk,\u0026nbsp;and\u0026nbsp;the support and guidance they considered necessary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analysed using a modified grounded theory approach (M-GTA), which emphasises the perspective of direct social interactions between individuals and is particularly suitable for process-oriented\u0026nbsp;phenomena. It is a qualitative research method that generates original theories through data-driven analysis,\u0026nbsp;aimed at\u0026nbsp;the practical application of the resulting theory \u003csup\u003e12)\u003c/sup\u003e. The rationale for using this method\u0026nbsp;was\u0026nbsp;that the experiences of mothers of\u0026nbsp;VLBWIs\u0026nbsp;regarding DHM represent a process-oriented phenomenon. Furthermore, as the study focuses on mothers who are expressing their own milk while using DHM, and their experiences evolve through interactions with their\u0026nbsp;infants, family members, and healthcare professionals, a perspective of social interaction is essential.\u0026nbsp;Therefore, M-GTA was considered appropriate for this study, whose analytical focus was\u0026nbsp;\u0026lsquo;mothers of VLBWIs who had progressed well after birth\u0026rsquo;. The analytical theme was defined as\u0026nbsp;\u0026lsquo;the process through which mothers using DHM for the first time come to reconcile their\u0026nbsp;sentiments\u0026rsquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterviews were audio-recorded and transcribed verbatim. To ensure the credibility of the analysis, the analysis was conducted under the guidance of a supervisor experienced in the M-GTA methodology.The specific analytical procedures were as follows:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eInterviews conducted with participants using the interview guide were transcribed verbatim and thoroughly reviewed.\u003c/li\u003e\n \u003cli\u003eThe transcript containing the richest content relevant to the analytical theme was selected as the initial data for analysis.\u003c/li\u003e\n \u003cli\u003eUsing an analytical worksheet, the selected transcript was examined in relation to the analytical focus and theme. Sections most relevant to the theme were identified as initial exemplars, definitions were assigned, and concepts were generated. Subsequently, additional exemplars from other sections of the transcripts were compared with the initial definitions and concept names and added to the variation column.\u003c/li\u003e\n \u003cli\u003eThrough constant comparative analysis, new concepts were generated while analysing the data. For each concept, a new analytical worksheet was created, and similarities and opposites were also examined.\u003c/li\u003e\n \u003cli\u003eAfter the final data analysis, it was confirmed that no new concepts were emerging, categories were generated, and theoretical saturation was determined.\u003c/li\u003e\n \u003cli\u003eRelationships among the categories were examined, and a result diagram and storyline were developed.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSample Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 10 participants were Japanese, married, using DHM for the first time, and aged 27\u0026ndash;39 years (mean 34 years, standard deviation [SD] 4.3 years),\u0026nbsp;They\u0026nbsp;had\u0026nbsp;all\u0026nbsp;intended to breastfeed their infants with their own milk whenever possible, ideally exclusively. Four were primiparous,\u0026nbsp;and six were multiparous, with two\u0026nbsp;multiparous participants having twins. Overall,\u0026nbsp;they had\u0026nbsp;no physical or mental health issues.\u003c/p\u003e\n\u003cp\u003eGestational ages at birth ranged from 23 weeks and 4 days to 30 weeks and 3 days (mean 27 weeks and 3 days, SD 2 weeks and 3 days). At the time of the interviews, all participants were using DHM. Interviews were conducted between one and four months postpartum (mean 48 days). Participants\u0026rsquo; demographic and clinical characteristics are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Participant characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1774277323.png\" width=\"747\" height=\"667\"\u003e\u003c/p\u003e\n\u003cp\u003eThe analysis yielded 17 concepts, 7\u0026nbsp;subcategories, and one core category. Data saturation was confirmed after the tenth interview. Figure 1 illustrates the relationships among the categories and the overall process identified in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStoryline\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMothers using DHM for the first time\u0026nbsp;expressed a strong desire for【\u003cstrong\u003eBonding through mother\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003es own milk\u003c/strong\u003e】yet giving birth to a very low birth weight infant created a\u0026nbsp;conflict between【\u003cstrong\u003ePrioritize the child\u0026apos;s life\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e and experiencing【\u003cstrong\u003eAnxiety about using DHM\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e, reflecting a\u003cstrong\u003e『\u003c/strong\u003e\u003cstrong\u003eConflict between genuine sentiment and reality\u003c/strong\u003e\u003cstrong\u003e』\u003c/strong\u003e. However, through\u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eWords from those who stay beside the mother\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e, mothers chose to use DHM. During the prolonged period of milk expression, they experienced\u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eLoneliness of being apart from the Infant\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e, but \u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eWords from those who stay beside the mother\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003ealso helped them gain\u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eRecognizing the role of DHM\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e. As a result, while some internal conflict remained, mothers reaffirmed the value of their own milk and came to\u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eReconciliation through expressing milk and the infant\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003es growth\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategories and Concepts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe meanings and illustrative examples of the categories and concepts are presented as follows. In the following text, core categories are enclosed in 『 』, categories in 【 】, concepts in ＜＞, and narratives are separated into independent paragraphs. Supplementary explanations are indicated in ( ).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCore\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCategory\u003c/strong\u003e: \u003cstrong\u003e『\u003c/strong\u003e\u003cstrong\u003eConflict between genuine sentiment and reality\u003c/strong\u003e\u003cstrong\u003e』\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is composed of 7 subcategories, that have been described in detail in the following sections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1\u003c/strong\u003e: \u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003ePrioritise the Child\u0026rsquo;s Life\u003c/strong\u003e\u003cstrong\u003e】\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt reflects mothers\u0026rsquo; understanding, based on physicians\u0026rsquo; explanations of the potential adverse effects of formula feeding on VLBWIs, and their recognition that DHM serves as a substitute when their own milk production is insufficient, ultimately contributing to their infants\u0026rsquo; survival. It is composed of two concepts:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1\u003c/strong\u003e\u003cstrong\u003e: \u0026lt;Understanding the risks of formula feeding\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that understanding the adverse effects of formula feeding allows mothers to reaffirm the benefits of providing their own breast milk to their\u0026nbsp;infants,\u0026nbsp;thereby supporting their decision to use DHM as one of the options. \u003c/p\u003e\n\u003cp\u003eWhen I first heard that giving formula might cause intestinal perforation, I thought, \u0026ldquo;How wonderful breast milk is!\u0026rdquo; Considering that the number of births is decreasing and fewer mothers are able to provide their own milk, I felt deeply grateful that there are mothers willing to give breast milk. Without them, this infant might not have grown as well. Thanks to this system, some infants are able to grow and thrive. （I）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;\u0026lt;As one who saves a child\u0026rsquo;s life, I am grateful\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that in the context of critical care for infants, mothers can feel gratitude for DHM,\u0026nbsp;as it has the potential to save their child\u0026rsquo;s life, even though it is someone else\u0026rsquo;s milk.\u003c/p\u003e\n\u003cp\u003eI did not hesitate to use DHM. From the beginning, I thought that if it was better for my child than formula, even a little, that was what mattered. My own feelings were secondary; what was important was doing what was best for my child. I had no negative impressions initially, and I have felt grateful for it from the start, without any change in that perception.（C）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2\u003c/strong\u003e: \u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eBonding through mother\u0026rsquo;s own milk\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt reflects mothers\u0026rsquo; desire to nurture their infants with their own breast milk, ideally without using DHM. However, given the reality that their own milk production is insufficient immediately after birth, mothers wish to provide at least the first feed with their own milk for establishing a bond with their child. It is composed of three concepts:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1\u003c/strong\u003e: \u003cstrong\u003e\u0026lt;Truthfully, I want to\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003egive\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003emother\u0026rsquo;s own milk\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores mothers\u0026rsquo; desire to feed their infants with their own breast milk, however, they face a reality where their own milk production is insufficient immediately after birth.\u003c/p\u003e\n\u003cp\u003eIf my milk had come in, of course, I would have wanted to feed my infant with my own breast milk from the very beginning. (G)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2\u003c/strong\u003e: \u003cstrong\u003e\u0026lt;I want to bond with my child\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;concept underscores that mothers wish to establish a bond with their infant by providing at least the first feed with their own milk, reflecting both their desire and the infant\u0026rsquo;s needs.\u003c/p\u003e\n\u003cp\u003eWhat does it mean\u0026hellip; hmm\u0026hellip; well, I think it comes from the desire for my child to grow and develop. I also feel a sense of connection, though the child may not understand my feelings\u0026mdash;it might just be my own ego, haha. (F)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;3\u003c/strong\u003e: \u003cstrong\u003e\u0026lt;\u003c/strong\u003e \u003cstrong\u003eOnly the first feed with mother\u0026rsquo;s own milk \u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that mothers wish to provide at least the first feed to their\u0026nbsp;infants\u0026nbsp;with\u0026nbsp;their own milk, reflecting their desire and intention.\u003c/p\u003e\n\u003cp\u003eDuring hospitalisation, when my expressed milk was collected and I saw it glisten, the midwife encouraged me to let the infant have it, saying, \u0026ldquo;Please let them take it in their mouth\u0026rdquo;. At that moment, I felt very happy, and I realised that in my heart I had always wanted the first feed to be my own breast milk.（I）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;3\u003c/strong\u003e:\u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eAnxiety about using DHM\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt reflects that mothers face a situation, where they must choose DHM because their own milk production is insufficient for their infant, which is directly linked to the infant\u0026rsquo;s survival. Simultaneously, using DHM raises various concerns because it is someone else\u0026rsquo;s milk. It is composed of two concepts:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003eWe have no choice but to select it as a\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026lsquo;\u003c/strong\u003e\u003cstrong\u003estopgap measure\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e＞\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that mothers face an inevitable situation where they must choose DHM because the insufficient production of\u0026nbsp;their\u0026nbsp;own milk is directly linked to\u0026nbsp;their infant\u0026rsquo;s\u0026nbsp;survival.\u003c/p\u003e\n\u003cp\u003eSo, I said, \u0026ldquo;Please go ahead\u0026rdquo;. It felt as if there were no real choice. I was told that DHM is better for digestion than formula, and I thought, \u0026ldquo;Well, then I\u0026rsquo;ll go with DHM\u0026rdquo;,\u0026mdash;there really wasn\u0026rsquo;t an alternative. (C)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;\u0026lt;Anxiety about the impact of opaque lifestyle characteristics\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that mothers experience anxiety regarding DHM due to its providers\u0026rsquo; uncertain lifestyle characteristics. \u003c/p\u003e\n\u003cp\u003eWell, if it is my own milk, I know, at least to some extent, what has gone into it\u0026mdash;for example, the food I ate yesterday becomes part of my blood and then my milk, even if it is far from perfect. But with someone else\u0026rsquo;s breast milk, I cannot know these details. (D)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;4\u003c/strong\u003e:\u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eWords from those who stay beside the mother\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt describes the process by which mothers move forward in accepting and reconciling with the use of DHM through trusted individuals\u0026rsquo; supportive words, and is composed of four concepts:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1\u003c/strong\u003e: \u003cstrong\u003e\u0026lt; Positive words from the husband \u0026gt;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis concept underscores that positive words from the husband, who is a life partner in child-rearing, guides and supports the mother in choosing to use DHM. \u003c/p\u003e\n\u003cp\u003eYes, I think I probably could not have made the decision on my own. It started with wondering, \u0026ldquo;What exactly is donor human milk?\u0026rdquo; I also found myself thinking about what kind of person the donor was, and what the milk might be like. My husband\u0026rsquo;s positive attitude, however, helped me feel that it was okay and supported me in making the decision. (F)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2\u003c/strong\u003e: \u003cstrong\u003e\u0026lt;\u003c/strong\u003e \u003cstrong\u003eWords from trusted, experienced mothers \u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that, in situations where mothers must rely on others\u0026nbsp;\u003c/p\u003e\n\u003cp\u003einstead of their own breast milk, positive words from someone with a maternal\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eexperience, with whom they can share and relate, serve as a source of support. \u003c/p\u003e\n\u003cp\u003eAh, yes. I talked with my mother and friends, and they said that since it is breast milk, it is easier to digest, and if it can be borrowed, it is something to be grateful for. Hearing these words gradually gave me a positive perspective and I think they helped me approach the situation with a forward-looking mindset.(H)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;3\u003c/strong\u003e: \u003cstrong\u003e\u0026lt;Words from a husband who cherishes his wife and child\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that mothers trust their husbands, who unconditionally prioritise the well-being of both mother and infant, and are able to accept and be reassured by their supportive words. \u003c/p\u003e\n\u003cp\u003eWell, I think the decision was probably not wrong. He considered not only the child, but also me, when making the decision, and that left me with no sense of anxiety. (B)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;4\u003c/strong\u003e: \u003cstrong\u003e\u0026lt;Words from doctors and nurses on children\u0026rsquo;s growth\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that words\u0026nbsp;from\u0026nbsp;physicians and nurses involved in\u0026nbsp;their\u0026nbsp;infant\u0026rsquo;s daily care\u0026nbsp;and growth,\u0026nbsp;serve as\u0026nbsp;triggers\u0026nbsp;for mothers to come to terms with\u0026nbsp;using\u0026nbsp;DHM.\u003c/p\u003e\n\u003cp\u003eYes, the staff informed me about how much milk my child was consuming, and how well the milk was being digested. They also provided updates on the child\u0026rsquo;s weight.Seeing how much my child has grown made me feel very positive. Overall, I have no concerns and feel grateful for their attentive care as my child is thriving. (D)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;5\u003c/strong\u003e: \u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eLoneliness of Being Apart from the Infant\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt describes how prolonged periods of expressing breast milk while the infant is not physically present can lead mothers to experience feelings of loneliness, and cause fluctuations in perceptions of their maternal role. It is composed of two concepts:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1\u003c/strong\u003e: \u003cstrong\u003e\u0026lt;Emptiness in expressing milk alone\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that expressing breast milk in the infant\u0026rsquo;s absence evokes a sense of loneliness and feeling of futility owing to the immediate lack of reward.\u003c/p\u003e\n\u003cp\u003eYes, I do have the desire to deliver the expressed milk, at least in thought, but I feel that I\u0026rsquo;m not fully motivated from the bottom of my heart. The pure intention of \u0026ldquo;I must deliver it\u0026rdquo; seems to have faded, and it feels somewhat mechanical, like a routine task. (A)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e \u003cstrong\u003e\u0026lt;Fluctuation in the ideal image of motherhood\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept refers to the phenomenon, in which, insufficiency of mother\u0026rsquo;s own\u003c/p\u003e\n\u003cp\u003emilk challenges or destabilises her perception of her ideal maternal self. \u003c/p\u003e\n\u003cp\u003eHonestly, at first I thought, \u0026ldquo;Oh, donor milk\u0026hellip; so my baby is drinking another mother\u0026rsquo;s milk\u0026hellip;\u0026rdquo; I felt a strong sense of disappointment and guilt, as if I couldn\u0026rsquo;t provide it myself. Not blaming myself per se, but I felt sorry. (J）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;6\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eRecognising the role of DHM\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt represents the realisation that when mother\u0026rsquo;s own milk is insufficient, the availability of DHM provides reassurance, given that, despite being another person\u0026rsquo;s milk, it serves the same purpose of supporting the infant\u0026rsquo;s healthy growth. It is composed of two concepts:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e \u003cstrong\u003e\u0026lt;Reassurance from being supported\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that mothers feel reassured knowing that DHM can support their infant\u0026rsquo;s growth in alignment with their own maternal intentions, serving as a supplement when their own milk production is insufficient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI feel that everything will be all right as long as my baby can grow with breast milk, even if it is from another mother. What matters most is that my baby grows healthy. If I had to rely solely on my own milk, I would probably feel pressured and exhausted. But knowing that DHM is available gives me a sense of relief \u0026mdash; it provides emotional comfort and peace of mind. (D)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2\u003c/strong\u003e\u003cstrong\u003e: \u0026lt;It remains human breast milk\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores the perception that DHM is equivalent to maternal breast milk in sustaining an infant\u0026rsquo;s life. Mothers expressed reassurance in recognising that, although the milk comes from another person, it serves the same purpose of supporting their infant\u0026rsquo;s survival and healthy growth. \u003c/p\u003e\n\u003cp\u003eWell, there was no one around me who had used it before; so, I did not have any prior experience or information. However, with formula, there can be compatibility issues, and I was not sure if it could meet the needs of a preterm infant. In contrast, I perceive breast milk as inherently beneficial, and therefore I considered DHM to be very good. (H)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;7\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e【\u003c/strong\u003e\u003cstrong\u003eReconciliation through expressing milk and the infant\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003es growth\u003c/strong\u003e\u003cstrong\u003e】\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt represents how mothers reconcile their experiences by recognising the benefits of breast milk. Such recognition enhances their motivation to continue breastfeeding through milk expression, and allows them to appreciate their infants\u0026rsquo; steady growth despite lingering internal conflict. It comprises two concepts:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1\u003c/strong\u003e\u003cstrong\u003e: \u0026lt;Continuing breastfeeding going forward\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that because of using DHM, mothers observe their infants\u0026rsquo; healthy growth and recognise the benefits of breast milk, which in turn,\u0026nbsp;motivates them to continue breastfeeding. \u003c/p\u003e\n\u003cp\u003eWell, I do think mother\u0026rsquo;s own milk\u0026nbsp;is special. Although I used donor milk, I still wanted to give my own milk as much\u0026nbsp;as possible. I was told it helps with immunity, and seeing that made me feel it\u0026rsquo;s important. So, I want to continue breastfeeding. (F)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e \u003cstrong\u003e\u0026lt;\u0026nbsp;With the conflict feelings, I am grateful for my child\u0026rsquo;s growth\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis concept underscores that, although mothers retain some emotional ambivalence, they experience gratitude for their infant\u0026rsquo;s healthy growth,\u0026nbsp;facilitated by the use of\u0026nbsp;DHM.\u003c/p\u003e\n\u003cp\u003eThe complex feelings towards donor human milk decrease somewhat as the infant grows\u0026mdash;not entirely, but the mother feels grateful for the support of the donor, recognising that the milk contributed to her child\u0026rsquo;s wellbeing. (B)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study employed semi-structured interviews and analysed the data using M-GTA, which yielded one core category and seven subcategories.\u003c/p\u003e \u003cp\u003eBased on this study\u0026rsquo;s results, three key points are discussed.\u003c/p\u003e \u003cp\u003eFirst, mothers experience a\u003cb\u003e『Conflict between genuine sentiment and reality』\u003c/b\u003ewherein their genuine desire relating to\u003cb\u003e【 Bonding through mother\u0026rsquo;s own milk】\u003c/b\u003e coexists with the necessity to \u003cb\u003e【Prioritise the child's life】\u003c/b\u003eand\u003cb\u003e【Anxiety about using DHM】\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eSecond, mothers reconcile their experiences through the influence of\u003cb\u003e【Words from those who stay beside the mother】\u003c/b\u003eand achieve a balance between\u003cb\u003e【Reconciliation through expressing milk and the infant\u0026rsquo;s growth】.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThird, \u003cb\u003e【Words from those who stay beside the mother】\u003c/b\u003eprovided insights for clinical nursing practice.\u003c/p\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eThe mothers\u0026rsquo;『Conflict between genuine sentiment and reality』\u003c/h2\u003e \u003cp\u003eThe mothers expressed that giving birth to an ELBWI led them to grapple with their situation\u0026rsquo;s reality, while simultaneously holding a genuine desire for\u003cb\u003e【Bonding through mother\u0026rsquo;s own milk】\u003c/b\u003e. During gestation, mothers and their infants are connected via the placenta and umbilical cord, creating a unified mother\u0026ndash;infant dyad. However, birth physically separates mothers from their infants. For mothers of preterm infants, in particular, breastfeeding serves as a means of reconstructing the maternal\u0026ndash;infant bond, and represents an act that only the mother can provide for her child\u003csup\u003e13)\u003c/sup\u003e. \u0026lt;I want to bond with my child \u0026gt;This maternal desire may be reflected in expressing breast milk to the infant, which could serve as a means of re-establishing connection with the separated newborn.\u003c/p\u003e \u003cp\u003eFor mothers who have given birth to preterm infants requiring NICU hospitalisation, breastfeeding represents the only act that only they can do for their babies\u003csup\u003e14)\u003c/sup\u003e. Therefore, to establish a bond with the child, it may be necessary that \u0026lt;Truthfully, I want Mother\u0026rsquo;s own milk \u0026gt;, rather than DHM. Breast milk protects preterm infants from complications such as NEC\u003csup\u003e15)\u003c/sup\u003e. This is equivalent to sustaining the infant\u0026rsquo;s life, and stabilising the infant\u0026rsquo;s condition can alleviate maternal guilt associated with preterm birth\u003csup\u003e14)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis desire is about establishing an emotional bond with the infant, and reflects the mother\u0026rsquo;s earnest wish for her baby\u0026rsquo;s healthy growth. It may be linked to the mother\u0026rsquo;s\u0026thinsp;\u0026lt;\u0026thinsp;Only the first feed with the Mother\u0026rsquo;s own milk \u0026gt;, as a way of conveying that heartfelt wish to feed her child. Fulfilling this desire is essential for supporting mothers in accomplishing their maternal role.\u003c/p\u003e \u003cp\u003e \u003cb\u003e【Words from those who stay beside the mother】\u003c/b\u003eand【\u003cb\u003eReconciliation through expressing milk and the infant\u0026rsquo;s growth】\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePreterm infants\u0026rsquo; birth often occurs as an emergency, and during hospitalisation, explanations are primarily directed to the father. When prior information regarding DHM has not been provided, fathers frequently receive explanations about DHM, alongside updates on the infant\u0026rsquo;s condition. However, as breast milk is a highly sensitive matter, it is essential to respect the mother\u0026rsquo;s feelings.\u003c/p\u003e \u003cp\u003eThis study\u0026rsquo;s findings indicate that mothers decide to use DHM with the support and presence of attentive husbands, and trusted experienced mothers. Subsequently, through interactions with their husbands who cherish them and their child, trusted experienced mothers, and guidance from doctors and nurses, mothers recognise the importance of breast milk and observe their infants\u0026rsquo; growth. This process enables them to reconcile their conflicting feelings regarding the use of DHM.\u003c/p\u003e \u003cp\u003eWhen a mother must make a decision, such as whether to use DHM, or when she feels uncertain or lost, support from close family members is crucial.\u003c/p\u003e \u003cp\u003eMothers seek approval and support from their families even during pregnancy\u003csup\u003e16)\u003c/sup\u003e. Previous studies have reported that a mother\u0026rsquo;s primary sources of information are her husband/partner, and/or her own mother \u003csup\u003e17)\u003c/sup\u003e. Among these, support from the husband/partner is particularly important, as it bolsters the mother\u0026rsquo;s confidence\u003csup\u003e17)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eProviding mothers with specific information from healthcare professionals about their infant\u0026rsquo;s condition and associated care promotes maternal well-being, and influences caregiving practices\u003csup\u003e18)\u003c/sup\u003e. In cases of preterm birth, mothers often experience guilt about delivering a small infant, and stress from being unable to engage in typical caregiving. Therefore, encouraging maternal contact, participating in care, and breastfeeding fosters bonding and enhances maternal satisfaction\u003csup\u003e19)\u003c/sup\u003e. In sum, healthcare professionals need to inform mothers about their infant\u0026rsquo;s growth and condition while using DHM, to support breastfeeding, and facilitate maternal participation in care to the extent possible.\u003c/p\u003e \u003cp\u003eFurthermore, the findings reveal a positive outlook \u0026lt;Continuing breastfeeding going forward\u0026gt;, along with expressing gratitude for the infant\u0026rsquo;s growth despite lingering ambivalence\u0026mdash;that is,\u0026lt;With the conflict feelings, I am grateful for my child\u0026rsquo;s growth\u0026gt;\u0026mdash;enables mothers to reconcile the『Conflict between genuine sentiment and reality』.\u003c/p\u003e \u003cp\u003eAs DHM is another person\u0026rsquo;s milk, mothers may experience barriers, such as fear of infection, aversion to another person\u0026rsquo;s bodily fluids, and concerns regarding bonding \u003csup\u003e20)\u003c/sup\u003e. Nevertheless, by providing their own breast milk to their infants and simultaneously recognising its benefits, mothers can also develop gratitude towards DHM\u003csup\u003e21)\u003c/sup\u003e. To provide appropriate support, healthcare professionals need to understand the impact of breast milk on mother\u0026ndash;infant dyads. Importantly, the significance of a mother\u0026rsquo;s own milk for mothers of preterm infants, who through caring for their child and wishing for their health, can deepen attachment, enhance maternal confidence, and accept their situation\u003csup\u003e22)\u003c/sup\u003e. This may also contribute to the mother\u0026rsquo;s understanding that given the importance of breast milk, supplementing DHM with her own milk is essential. Furthermore, as previous research has indicated, mothers of preterm infants are deeply concerned about their child\u0026rsquo;s health \u003csup\u003e22)\u003c/sup\u003e. Sharing information about their infants\u0026rsquo; growth can be considered a factor that facilitates the mother\u0026rsquo;s process of reconciling conflicting feelings. Therefore, healthcare professionals should provide breastfeeding support while clearly communicating the infant\u0026rsquo;s condition to the mother and actively facilitating her participation in care.\u003c/p\u003e \u003cp\u003eClinical Implications for Nursing from the Category of\u003cb\u003e【Words from those who stay beside the mother】\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFamily relationships play a crucial role in helping mothers using DHM to accept and reconcile with it. Midwives need to understand these relationships, and provide care that involves and supports the family as a whole. This study\u0026rsquo;s participants had supportive families; however, in recent years, family structures have become more diverse, including nuclear families and single-parent households. Some mothers may lack immediate familial support; therefore, healthcare professionals\u0026rsquo; role is particularly significant. Facilitating connections among mothers who have given birth to preterm infants and used DHM, and providing opportunities for group gatherings, is important. Additionally, prenatal education should provide all expectant mothers and parents with knowledge about preterm birth, emphasising the importance of preparation and awareness before delivery. Prenatal education equips mothers to better cope with unexpected situations; hence, preparing and educating mothers is considered the responsibility of healthcare professionals\u003csup\u003e23)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHealthcare professionals themselves were also perceived as those who【from those who stay beside the mother】.Mothers of preterm infants often experience compounded stress, including guilt related to preterm birth and emotional ambivalence regarding DHM use. Prolonged separation in many cases can place a significant burden on parents, who have lost confidence in their parental role\u003csup\u003e24)\u003c/sup\u003e. Long-term physical separation between mother and infant has also been reported to induce maternal stress, anxiety, and depression\u003csup\u003e25)\u003c/sup\u003e, which may, in turn, affect preterm infants\u0026rsquo; future development.\u003c/p\u003e \u003cp\u003eFrom an early stage, healthcare professionals need to recognise that mothers\u0026mdash;and their partners\u0026mdash;may wish to provide mother\u0026rsquo;s breast milk, while also thoroughly explaining the following: benefits of breast milk, that DHM is intended for use only when maternal milk is insufficient, and the potential influence of donor-related factors, such as infectious diseases, genetics, lifestyle, and health status on milk quality. When mothers receive such comprehensive explanations, they are able to provide informed consent for using DHM\u003csup\u003e26)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eProviding breast milk is an activity that makes a mother feel indispensable\u003csup\u003e13)\u003c/sup\u003e. This process allows mothers to feel connected to their children and support their health, thereby fostering a sense of well-being. Simultaneously, it partially mitigates the sadness associated with the physical separation from the infant \u003csup\u003e27)28)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFinally, recognising that mothers have a strong desire to know about their preterm infants\u0026rsquo; condition \u003csup\u003e18)\u003c/sup\u003e, and pray for their health \u003csup\u003e22)\u003c/sup\u003e, healthcare professionals should provide them with daily updates on their child\u0026rsquo;s growth. Observing their infants\u0026rsquo; growth allows mothers to feel that choosing DHM, primarily to protect the child from complications, was the correct decision\u003csup\u003e26)\u003c/sup\u003e. Continued breastfeeding, combined with monitoring the child\u0026rsquo;s development, contributes to the process by which mothers reconcile their \u003cb\u003e『Conflict between genuine sentiment and reality』\u003c/b\u003eregarding the use of donor human milk (DHM). Furthermore, sustained breastfeeding plays a crucial role in strengthening maternal confidence, fostering mother\u0026ndash;infant bonding, and supporting the infant\u0026rsquo;s optimal growth and health.\u003c/p\u003e \u003cp\u003eOne possible explanation is that staff education and the provision of consistent breastfeeding information to families promote mothers\u0026rsquo; acceptance of DHM as a temporary bridge, which may lead to higher rates of mothers subsequently providing their own milk. Indeed, Delfosse et al reported that, following staff training and unified breastfeeding support, more than 80% of mothers ultimately provided their own milk to their infants\u003csup\u003e29)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has several limitations. It was conducted within a Japanese cultural context and included only 10 mother\u0026ndash;infant dyads with favourable prognoses. Consequently, all the participants were in situations where they could receive support from their families. If family consent or support is unavailable, the process by which mothers come to terms with using DHM may differ. Furthermore, as it focused exclusively on mothers, fathers\u0026rsquo; perspectives and evolving experiences on DHM were not explored. Hence, future research should explore them, both in their own right and in their role as supporting partners, to examine how each parent\u0026rsquo;s feelings interact with one another.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe process by which mothers of ELBWIs reconcile their feelings when using DHM for the first time was elucidated by identifying 17 concepts, seven subcategories, and one core category. Although mothers experienced a『Conflict between genuine sentiment and reality』regarding the use of DHM, support through 【Words from those who stay beside the mother】enabled them to decide to use DHM and achieve【Reconciliation through expressing milk and the infant\u0026rsquo;s growth】. These findings underscore the importance of providing all expectant parents with prenatal breastfeeding education that includes information about preterm birth and DHM. Moreover, healthcare professionals supporting mothers of preterm infants using DHM should understand this psychological process, and recognise their own role in offering【Words from those who stay beside the mother】, and thereby provide effective support.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVLBWIs: very low birth weight infants\u003c/p\u003e\n\u003cp\u003eDHM: donor human milk\u003c/p\u003e\n\u003cp\u003eNEC:\u0026nbsp;necrotising enterocolitis\u003c/p\u003e\n\u003cp\u003eNICUs: neonatal intensive care units\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Nara Medical University Ethics Committee (approval no. 3885). Written informed consent was obtained from all participants. There was no remuneration for involvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMM\u0026nbsp;\u003c/strong\u003edesigned the study, conducted the interviews, analysed the data, prepared the figures and tables, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYT\u0026nbsp;\u003c/strong\u003eprovided an explanation of the study to the patient and obtained preliminary consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYU\u0026nbsp;\u003c/strong\u003esupervised the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTI\u0026nbsp;\u003c/strong\u003esupervised the study, supported data analysis and the preparation of figures and tables, and edited the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank the mothers who participated in this study. We also thank Prof. Kumiko Kotake (Department of Home Nursing, Nara Medical University) and Prof. Koji Yamazaki (Graduate School of Health and Social Sciences, Shizuoka University) for their valuable guidance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations Children\u0026rsquo;s Fund (UNICEF). The State of the World\u0026rsquo;s Children 2024: Statistical Compendium. New York (NY): UNICEF; 2024. Available from:https://data.unicef.org/resources/sowc-2024/\u003c/li\u003e\n\u003cli\u003eMinistry of Health, Labour and Welfare (JP). Live births and percentage distribution according to birth weight and mean birth weight, 1975\u0026ndash;2019 [Internet]. Tokyo: Ministry of Health, Labour and Welfare; 2021 [cited 2025 Sep 8]. Available from: https://www.mhlw.go.jp/english/database/db-hw/FY2021/dl/live_births03.pdf\u003c/li\u003e\n\u003cli\u003eSato M, Hamada Y, Kohno M, Ise K, Uchida K, Ogata H, et al. 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PubMed PMID: 17353730.\u003c/li\u003e\n\u003cli\u003eEsquerra-Zwiers A, Rossman B, Meier P, Engstrom J, Janes J, Patel A. \u0026quot;It\u0026apos;s Somebody Else\u0026apos;s Milk\u0026quot;: Unraveling the Tension in Mothers of Preterm Infants Who Provide Consent for Pasteurized Donor Human Milk. J Hum Lact. 2016;32(1):95-102. Epub 20151120. doi: 10.1177/0890334415617939. PubMed PMID: 26590179; PubMed Central PMCID: PMC4959541.\u003c/li\u003e\n\u003cli\u003eSweet L. Birth of a very low birth weight preterm infant and the intention to breastfeed \u0026apos;naturally\u0026apos;. Women Birth. 2008;21(1):13-20. Epub 20071226. doi: 10.1016/j.wombi.2007.11.001. PubMed PMID: 18162451.\u003c/li\u003e\n\u003cli\u003eSweet L. Expressed breast milk as \u0026apos;connection\u0026apos; and its influence on the construction of \u0026apos;motherhood\u0026apos; for mothers of preterm infants: a qualitative study. Int Breastfeed J. 2008;3:30. Epub 20081217. doi: 10.1186/1746-4358-3-30. PubMed PMID: 19091075; PubMed Central PMCID: PMC2628335.\u003c/li\u003e\n\u003cli\u003eDelfosse NM, Ward L, Lagomarcino AJ, Auer C, Smith C, Meinzen-Derr J, et al. Donor human milk largely replaces formula-feeding of preterm infants in two urban hospitals. J Perinatol. 2013;33(6):446-51. Epub 20121220. doi: 10.1038/jp.2012.153. PubMed PMID: 23258498; PubMed Central PMCID: PMC3810409.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Donor human milk, Modified grounded theory approach, Neonatal intensive care unit, Mother’s own milk, Very low birth weight infants","lastPublishedDoi":"10.21203/rs.3.rs-8890909/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8890909/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003cbr\u003e\n \u003c/strong\u003eBreast milk reduces complications among very low birth weight infants (VLBWIs) admitted to neonatal intensive care units (NICUs). When mothers’ own milk (MOM) is temporarily unavailable, donor human milk (DHM) is used as an alternative. In Japan, where human milk banking has been introduced relatively recently, little is known about how mothers experience emotional changes and social interactions related to DHM use while continuing to express their own milk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSemi-structured interviews were conducted with 10 mothers of VLBWIs who had used DHM immediately after birth, and data were analysed using the Modified Grounded Theory Approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMothers experienced a conflict between their genuine feelings and the realities of donor human milk use; however, the words of those who stayed beside them, including midwives and physicians, facilitated meaning-making, enabling mothers to reconcile their experiences through expressing milk and their infant’s growth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e【Words from those who stay beside the mother】\u003c/strong\u003eprovided insights for clinical nursing practice. Continued breastfeeding and the child’s growth supported mothers in negotiating and reconciling the tension between their authentic feelings and the realities of using donor human milk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study clarified how mothers negotiate and reconcile emotional conflicts related to DHM use in NICUs. Emotional support from healthcare professionals, together with ongoing lactation support and opportunities to share experiences, may help mothers come to terms with DHM use and sustain milk expression. These findings provide practical implications for nursing support in settings where DHM is implemented. Providing continuous lactation support and opportunities to share experiences may help mothers come to terms with DHM use and sustain milk expression. Additionally, building connections among mothers, creating opportunities for peer gatherings, offering antenatal education that includes breastfeeding preparation, and enhancing lactation education for healthcare professionals are beneficial. These findings offer practical implications for breastfeeding support in settings where DHM is implemented.\u003c/p\u003e","manuscriptTitle":"Japanese Mothers’ Experiences and Sentiments Towards Donor Human Milk for Very Low Birth Weight Infants: A Modified Grounded Theory Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 10:27:34","doi":"10.21203/rs.3.rs-8890909/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-11T08:32:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T07:12:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8808307101546938444533523902502279975","date":"2026-05-02T11:46:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-22T12:12:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288046492908730496625319118214753729877","date":"2026-03-20T16:39:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-18T15:34:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-27T15:04:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-27T15:00:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Breastfeeding Journal","date":"2026-02-16T07:40:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a0b355a1-b638-423f-a2d1-caa012bd9e06","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-11T08:32:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T07:12:17+00:00","index":23,"fulltext":""},{"type":"reviewerAgreed","content":"8808307101546938444533523902502279975","date":"2026-05-02T11:46:14+00:00","index":22,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T05:23:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 10:27:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8890909","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8890909","identity":"rs-8890909","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}