Receiving Screened Donor Human Milk for Their Infant Supports Parental Wellbeing: a Mixed-methods Study

Receiving Screened Donor Human Milk for Their Infant Supports Parental Wellbeing: a Mixed-methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Receiving Screened Donor Human Milk for Their Infant Supports Parental Wellbeing: a Mixed-methods Study Amy Brown, Natalie Shenker This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1167440/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Donor human milk (DHM) protects the health and development of premature infants but there has been little examination of the broader impact of an infant receiving it upon parental mental health. Breastfeeding and mental health are closely tied with women who experience breastfeeding difficulties or are unable to meet their own breastfeeding goals often experiencing feelings of guilt, sadness and anger, alongside an increased risk of postnatal depression. The aim of the current study was to explore how experience of receiving DHM for their baby affected the wellbeing of parents. Methods: UK parents of infants aged 0 – 12 months who had received screened DHM from a milk bank (typically on the neonatal unit or in some cases in the community) completed an online questionnaire exploring their experiences. The questionnaire included Likert scale items examining perceived impact upon infant health, own wellbeing and family functioning alongside open-ended questions exploring perceptions of how receiving DHM affected wellbeing. Results: Almost all of the 107 participants (women=102) agreed that receiving DHM had a positive impact upon infant health and development, their own mental and physical health, and their family’s wellbeing. Parents felt relieved that their infant was receiving DHM for health reasons but also due to the experience of being listened to, supported and having their infant feeding decisions facilitated. Receiving DHM helped mothers to process some of their emotions at not being able to breastfeed, in part because knowing their baby was being fed gave them the space to focus on recovery and bonding with their baby. Some parents did experience challenges, feeling guilty at receiving DHM, insecure that another woman was able to feed their baby when they could not, with some negative reactions from family. Although the impact of receiving DHM upon breastfeeding was not measured, some women who were working to build their own milk supply noted that it helped motivate them to continue. Conclusions: DHM may play an important role not only in protecting infant health and development but in supporting the mental health and wellbeing of mothers for whom their infant receiving human milk is important. Maternal & Fetal Medicine Donor human milk Premature infant Breastfeeding Mental health Infant Mother Qualitative research Wellbeing Introduction Human milk is established as protecting infant health 1 , but is particularly important in protecting the health and development of premature infants. Premature infants who receive human milk are less likely to develop life-threatening conditions such as necrotising enterocolitis [NEC] 2 , late-onset sepsis, and have better cognitive development 3 . However, as a result of prematurity, mother-infant separation, and birth trauma, mothers of the smallest and sickest infants can struggle to produce or express enough milk for their baby 4 . For this reason, human milk banks (HMBs) were created to enable other mothers to donate their breastmilk. Donor human milk (DHM) reduces the incidence of NEC 5 – 7 , sepsis, 8 and bronchopulmonary dysplasia 9 . Infants fed with DHM rather than infant formula where there is a shortfall of maternal milk also tolerate full feeds more rapidly and leave hospital sooner 10 , with likely consequent cost-effectiveness in the hospital setting 11 . While research has typically focused on the health impacts in infants receiving DHM 12 or DHM content and variability 13 , increasing data from international sources shows a beneficial effect on maternal breastfeeding rates when DHM is available in the context of optimal lactation support 14 – 16 . There is a paucity of evidence regarding the experiences of families whose infants receive DHM and its impact on maternal mental health. In the USA, an interview study with 30 mothers of late pre-term and term babies who were using supplemental DHM identified that mothers perceived it as better for infant health, which reduced their anxiety 17 . Another US study that interviewed 50 mothers who received human milk via informal mother to mother sharing reported decreased stress and symptoms of postnatal anxiety and depression, again because they felt that DHM protected their baby. Some felt pride at being able to source milk for their baby, although others found the process stressful 18 . In 2019 a service evaluation of the Hearts Milk Bank, a new non-profit HMB in the UK, identified recurrent reports from parents who indicated receiving DHM for their baby had reduced their symptoms of anxiety and depression post-partum 19 . This study sought to add to this literature by conducting a larger mixed methods study examining the experiences of having received DHM upon parental mental health in a larger sample in the UK. Methodology Participants Parents in the UK with a baby aged 0 – 12 months who had received screened DHM from a milk bank participated in this study. This time period was selected to allow for sufficient participants to have received DHM and be able to reflect on their experiences but to reduce any risk of recall bias due to significant time passing since they received DHM. The decision was made to include both mothers and fathers / partners in the study because often fathers/ partners are instrumental in organising and collecting DHM. They may also be sourcing milk for an adopted infant or be caring solely for their infant if the mother is critically unwell or has died. STROBE guidelines were followed and full ethical permission for the study was gained from Swansea University Research Ethics Committee. Participants gave informed consent and all aspects of the study were carried out in line with the declaration of Helsinki. All participants gave informed consent prior to completing the survey. Measures Participants completed an online questionnaire containing both closed and open questions, hosted by Qualtrics. The questionnaire included: Demographic details (maternal age, education, ethnicity) Details of the infant that they received DHM for (age, sex, gestation at birth) Current milk feeding status of their infant (breastfeeding duration and exclusivity, formula use, DHM use, reasons for stopping breastfeeding if relevant) Details of DHM use (duration, exclusivity, approximate volume received, milk bank used) 5-point likert scale items examining perceived impact of DHM upon infant health and development, own wellbeing and family wellbeing [Strongly agree – strongly disagree] Open ended questions exploring experience of receiving DHM and perceived impacts upon infant health and development, own wellbeing and family wellbeing (Table 1 ) Table 1 Open ended questions exploring experiences of receiving donor human milk • Can you tell us a little about what motivated you to want donor milk for your baby? • How did receiving donor milk make you feel? • If you were also breastfeeding your baby, how did receiving donor milk affect your experience of breastfeeding? • What impact do you feel that donor milk had for your baby? • What impact do you feel that receiving donor milk had for you and your wider family? • How did your experience of donor milk fit with your expectations of receiving donor milk? Was it better? Different? More challenging than expected? • Finally, do you have any further comments on the experience of receiving donor milk? Procedure Data were collected for six months from June – December 2020. Adverts containing brief details of the study and inclusion criteria were placed on social media with encouragement for breastfeeding, milk banking and parenting organisations to share the post. Adverts contained a link to the study information sheet for further information followed by consent questions if interested participants wanted to continue. UK residence was confirmed by participants having a UK postcode. Only when all consent items were agreed did the full questionnaire load. Once completed a debrief statement was given, explaining the study, thanking them for participation, and giving them contact details for support organisations if needed. Data analysis Quantitative data were analysed using SPSS version 27 to compute descriptive statistics regarding perceptions and experience of DHM use. A thematic analysis was conducted on qualitative data from the open-ended questions using a simple descriptive analysis 20 . The first researcher immersed themselves in the data, reading through responses from each participant and across questions for all participants. Next responses were read and re-read to identify smaller themes. These smaller themes were then grouped into larger subthemes 21 . To enhance trustworthiness of the data 22 , initial coding was completed by one researcher, with a second reviewing themes and subthemes. Where disagreement occurred, themes were discussed until agreed. An example of the overall process of how the analysis moved from raw data to subtheme, to theme is shown in Table 2 . Table 2 Showing analysis process from raw data to theme Raw data Subtheme Subtheme description Theme Theme description ‘It’s hard to put in words how it felt to know I could still provide breast milk for the baby...it felt like an army of invisible mothers looking after us and felt very emotional and still does when I think back to it.’ Feeling connected to other mothers Women felt supported by and connected to a network of other women who had been kind enough to donate their milk to strangers. Feeling supported and care for The experience of receiving DHM from a milk bank helped mothers feel that someone was listening to them, seeing their desire to give their baby DHM and supporting them. All participants remained in the study if they completed the Likert scales examining their perceived impact of DHM. However, for the open-ended questions some participants [n = 5] gave short responses (providing only a few words over all open-ended questions), wrote that they were ‘unsure’ [n = 4] or left the open-ended questions blank [n = 3]. This left 95 participants (92 mothers and 3 fathers) who contributed to the qualitative analysis. Responses given were typically in depth and often crossed these themes and subthemes within one response (see Table 3 for a typical example response). Table 3 Example of typical depth and length of open-ended response ‘I cannot quite put into words the sheer relief that I felt when I learned that we would be able to access 3 litres of donor milk from the Hearts Milk Bank. We had been struggling with latching my tongue-tied baby for 3 weeks and she still hadn’t regained her birth weight. My partner has severe allergies which have affected him throughout his entire life. After 3 weeks of inefficient feeding my supply was impacted and my baby was hungry. I did not want to give her formula if at all avoidable as we suspected that my partner’s issues stem from being given formula as a first feed following his birth. Learning that we could access this donor milk to help bridge the gap between my supply and Ivy’s hunger while we worked to rebuild it (via expressing and taking supplements for 3 more months) was a feeling akin to having held my breath for 3 weeks and finally being able to breathe again. I broke down on the phone to [milk bank lead] who confirmed to us we would be able to have some milk. I was overjoyed overwhelmed with relief. I felt supported and justified finally in my desire to not have to resort to formula. I felt grateful and that somebody finally understood our desires and struggle’. (Mother) Results One hundred and seven participants completed the survey including 102 mothers and five fathers. Mean age of participants was 32.38 (SD: 5.80) with a range from 19 to 47 years. DHM was received for 115 infants (eight sets of twins) of which 48 (44.8%) were male. Age of infant at birth range from 24 to 43 weeks with a mean gestation of 33.1 weeks (SD: 4.64 weeks). Further demographic details are shown in Table 4 . Table 4 Participant demographic background. Indicator Group N % Age (yr) ≤ 19 2 1.8 20 – 24 9 8.5 25 – 29 21 21.4 30 – 34 32 28.1 ≥ 35 43 40.2 Education School 9 8.6 College 22 20.6 Higher 52 48.6 Postgraduate 24 22.4 Marital status Married Cohabiting Single Widowed 61 40 5 1 57.0 37.4 4.7 0.9 Ethnicity White 91 85.0 Gypsy / Traveller / Roma 1 0.9 Asian or Asian British (Bangladeshi, Indian, Pakistani) 4 3.8 Asian or Asian British (Chinese) Black or Black British Mixed or multiple Other 2 3 5 1 1.9 2.7 4.7 0.9 Parity First baby / first multiple birth 59 55.7 Second or more 48 44.3 Country England 86 80.4 Scotland 17 15.9 Wales 0 0.0 Northern Ireland 4 3.7 Receiving donor human milk Milk was received from nine different HMBs, including seven in England, one in Scotland and one in Northern Ireland (with 8.4% (n = 9 participants) not sure which milk bank provided their DHM). The majority of infants started receiving DHM in the first days of life. Overall, 35 infants (32.7%) received it from their day of birth, 40 (56.1%) by day three, and 95 (88.8%) by the end of the first week. However, age at starting DHM ranged from birth to 4 months old. Participants were asked the duration that their infant received DHM exclusively (receiving only DHM feeds) and non-exclusively (DHM alongside own milk or formula). The majority of infants received exclusive DHM at first, but for less than a week (n = 90, 84.1%). The majority of infants then went on to receive DHM alongside others milk for up to a week (n = 91, 85.0%). However, some infants received DHM for an extended period (Table 5 ). Table 5 Duration of DHM received. Duration Exclusive DHM Alongside other milk N % N % 0 days 17 15.9 0 0.0 1 - 7 days 69 64.5 91 85.0 8 – 14 days 6 5.4 5 4.6 15 – 21 days 8 7.4 3 4.6 22 – 28 days 3 2.7 2 1.8 29 - 35 days 0 0.0 0 0.0 36 – 42 days 2 1.9 2 1.9 43 – 49 days 1 0.9 1 0.9 50 – 56 days 0 0.0 0 0.0 57 – 63 days 0 0.0 0 0.0 64 – 70 days 1 0.9 1 0.9 When asked to estimate how much donor milk they received overall 59.8% (n = 64) provided an estimate with the remainder unsure. This ranged from less than 100ml spread across supplemental feeds to up to 70 litres. However, the majority of infants (n = 50, 76.6%) received 5 litres or less. Perceived impact of donor milk Participants were asked to rate the impact they felt receiving DHM had upon their infant and family (5-point likert scale from very positive to very negative). Participants perceived a very positive or positive impact on their baby for infant health (98.1%, n = 104), infant development (96.2%, n = 101), own mental health (96.2%, n = 101), own physical health (86.8%, n = 92) and family’s wellbeing (89.6%, n = 85). One participant in each case rated each aspect as having a negative impact with the remainder neutral. Exploring experiences of receiving donor milk Participants were asked a series of open-ended questions exploring their experiences of receiving donor human milk. A thematic analysis identified seven themes, consisting of 16 subthemes overall. Examples of quotes are given below, with details of participant: parent, age, ethnicity, and where provided details of breastfeeding complication). Theme one: Relief that their baby was receiving DHM for health reasons A central theme to emerge was the perceived impact parents felt that receiving DHM had on their infant’s health and development and the subsequent impact that this had upon parental wellbeing. Parents believed that their infant’s immune system was supported, alongside reassurance for those who were worried about family history of allergy. ‘It brings me great comfort knowing that I was optimising the amount of breastmilk she received. I genuinely believe that her immune system is great because she received different sources of antibodies on top of the antibodies I gave her.’ (Mother, 28, White, Low milk supply) ‘We have so many allergies between us and we were worried about her being so tiny and the effect that formula might have so we were very relieved to be able to supplement with DHM instead of formula. It helped reduce our anxiety and stress at a difficult time.’ (Father, 42, White, Premature baby). Theme two: Feeling supported and cared for The process of receiving DHM did not only affect parents in relation to feelings around how their baby was fed, but also helped them to feel cared for and supported, often at a very challenging point in time. Parents experienced this in a number of ways: Feeling listened to Many women talked about feeling listened to and respected in relation to how they wanted to feed their baby. It wasn’t just that they were given DHM but that someone asked them questions, listened to their story and saw how much they valued giving their baby DHM. ‘I expected to be laughed at to be honest but the woman I spoke to on the phone was just amazing. She was so kind and listened to how I felt and was so understanding and it made a real difference to my concerns.’ (Mother, 41, White, Low milk supply). Feeling cared for Parents also felt cared for at a difficult time. Typically, families were in late pregnancy or the early days of having a baby when they were told they needed to supplement their baby or would not be able to breastfeed. They already felt vulnerable and exhausted, yet someone was there helping and caring for them ‘I felt supported and like someone cared for me and my baby following diagnosed low supply.’ (Mother, 36, White, Insufficient glandular tissue) Feeling supported by and connected to other mothers Others felt supported by a wider community of breastfeeding mothers who were donating their milk to strangers. Women felt supported by people they had never met and overwhelmed that someone they did not know could be so kind. ‘It’s hard to put in words how it felt to know I could still provide breast milk for the baby...it felt like an army of invisible mothers looking after us and felt very emotional and still does when I think back to it.’ (Mother, 37) Notably, this feeling of connection and gratitude to other women helped encourage some mothers to carry on expressing their own milk and trying to build their supply. They felt that others had stepped up to support them without even knowing them and that they owed it to the community to keep trying. ‘I found the triple feeding in particular really difficult but then I thought about the women who had taken the time to donate their milk and all that entails and it motivated me to keep trying. It felt like they were supporting me in this even though we had never met.’ (Mother, 26, Black British, Faltering growth) Some mothers in the study then talked about the circle of going on to provide DHM themselves, feeling grateful of the opportunity to help others in their situation and that they were ‘paying back’ the kindness of others. ‘As soon as we were settled and feeding well I started to build up a stash of my own milk to donate back and it made me feel so good knowing it would likely go to a mum just like me who was stressed and desperate for help and I could play a part in changing all of that.’ (Mother, 28, Black, Premature baby) Theme three: Reducing the pressure in the early days Many participants talked about how receiving DHM made the intense days after a birth (which was often premature or traumatic) easier. DHM reduced pressure regarding providing expressed milk, increased bonding and supported family relationships. Reducing pressure to provide expressed milk / build supply Some women in the study were experiencing breastmilk supply difficulties and needed to supplement. Often women in this situation were trying to express milk for a premature baby who could not feed directly or were on a triple feeding plan whereby they breastfed their baby, topped up their baby with previously expressed milk and then tried to express more milk again. Although this can help build milk supply more quickly, it can feel exhausting for the mother. Receiving DHM in these circumstances helped reduce the pressure on mothers as they knew that their baby would be fed even if expressing did not go well that day. ‘I was so exhausted from trying to care for her and feed her and express. Just those few feeds of donor milk meant the pressure reduced and I could have a break from the ward for a bit. I think it made all the difference as allowed my stress to come down and for me to catch up on a bit of sleep. I think without that I might have given up breastfeeding altogether but that space, that physical and emotional space that donor milk allowed probably is a big part of why we’re still feeding now.’ (Mother, 32, White, Premature baby). Enabling bonding Linked to the reduction in pressure to produce sufficient breastmilk for their baby, some mothers described how this enabled them to take a step back and start to properly bond with their baby. It removed the stress from the relationship and feeding experience, allowing more positive interactions with their baby that weren’t focussed on attempting to produce more milk. ‘I think it helped us to bond better. Once I was less stressed and obsessed with making sure he just had my milk it felt as if everything eased between us?’ (Mother, 34, Asian Chinese, Premature baby) Supporting family relationships Related to taking the pressure off needing to provide sufficient breastmilk themselves, the consequence of this reduced stress and pressure rippled out into the broader experience of early parenting, the transition to motherhood / fatherhood and family relationships. Mothers in particular felt that they could focus some of their attention on other children and felt less tense around their partner. ‘Reduced stress for all family as I was not stressing about not being able to provide the milk’. (Mother, 33, White, insufficient glandular tissue) ‘I was a better mum for it, my husband benefitted from this and we felt stronger and united in the parenting journey’. (Mother, 47, White, HIV positive) Enabling partners to play a role Some mothers accessed DHM direct from the hospital when they were staying on the neonatal unit. However, others sourced DHM from milk banks who were able to provide some DHM to the community. In these cases DHM needed to be organised and collected. Although this could sometimes add an additional layer of stress, a number of parents in the study highlighted how it enabled the father / partner to be able to practically do something and feel like they were contributing to their baby being fed. ‘I was able to go and collect the milk for our baby and that really helped me feel like I was doing something and that I was able to look after my partner in a way because she was very distraught. It also gave me something practical to think about and do rather than worrying about them both all the time.’ (Father, 38, White. Premature baby). Theme four: Supporting preferred feeding choices Another central theme was the impact that receiving DHM had upon mothers (and sometimes partners) feeding plans and preferences. By the nature of this sample breastfeeding and receiving human milk was obviously very important to parents and having the option to be able to give their baby DHM played an important role in wellbeing, eliciting a whole host of emotions. These emotions typically split two ways: emotions at being able to provide DHM and emotions at being able to provide DHM. Opportunity to use DHM The positive emotional experience of having the opportunity to give their baby DHM, sometimes enabling their baby to have a fully human milk diet, or sometimes in combination with formula milk was clear. Women used words such as feeling ‘ grateful’ , ‘ relieved’ , ‘ proud’ and ‘ empowered’ at being able to give their baby DHM. ‘It reduced any complicated feelings of guilt, it provided peace of mind, it made me feel happy and proud’. (Mother, 35, White, Double mastectomy) The strength and depth of this relief was clear from many of the responses. Women didn’t simply feel a bit happier, but rather that their mental health was protected. ‘I was devastated when I realised I wasn’t going to produce enough milk myself for her and this felt like a genuine lifeline, that someone was pulling me out of a very dark place. I will always be so grateful to the support and kindness we received.’ (Mother, 29, Asian British Pakistani, Low milk supply) Opportunity to avoid giving formula milk Conversely many women described their relief and gratitude at not needing to use formula milk when this was not part of their feeding plan. ‘I can say my daughter has been exclusively breastfed - my son had about 40 ml of formula when he was born then breastfed until 3 but in my head I could never say he was exclusively breastfed all the way through and that stuck with me. I didn’t want that again. My values are very much against using formula if there is human milk available and I am so glad that we were able to access this. I would have been so unhappy if that first week had been formula top ups every 3 hours as it just a would have felt to me like putting something in my baby which I don’t believe in. ’ (Mother, 34, Low milk supply) Conflicted and mixed emotions However, although DHM allowed parents to feed their baby in the way they wanted, many did feel conflicted over using it. This was either in relation to not being able to exclusively breastfeed themselves, or feeling torn at another mother providing the milk for their baby. This sometimes compounded feelings of guilt that they weren’t providing milk for their baby directly themselves. ‘I felt guilty that it wasn’t my milk being given but grateful to be able to give breast milk rather than formula.’ (Mother, 28, White, Premature baby) Guilt at receiving DHM One challenging emotion experienced amongst some mothers was the guilt at receiving DHM for their baby, believing that it might be taken away from a more vulnerable baby. Some felt that they needed to justify why they were using it to others around them and tell people that they were trying to increase their milk supply to feel deserving of receiving it. ‘ [I felt] guilty for taking donor milk for my baby when more needy prem babies might miss out because we took the milk. I felt a constant need to explain to everyone all the things I was trying to get my supply up after my milk didn’t come in to justify having some donor milk to keep us going’. (Mother, 36, White, Tongue tie & latch issues) Theme five: Alleviating complex emotions at not being able to breastfeed Some mothers in the survey were using DHM to top up their own milk supply, sometimes due to having insufficient glandular tissue and therefore having a reduced supply or whilst waiting for their own milk supply to fully develop. Others were unable to breastfeed for health reasons and had sourced typically a small amount of DHM for their baby for the early weeks of life. The depth of emotion about how women felt at not being able to breastfeed or needing to supplement their baby was clear. However, receiving DHM supported maternal mental health in a number of ways. Reducing feelings of guilt Many women talked about the guilt they felt at not being able to breastfeed their baby even though in every case described there was a physiological reason why women could not produce sufficient milk or breastfeeding was contraindicated. ‘[I felt] so grateful that I could give my baby the best start in life, humbled that women would donate their precious milk to people like me and less guilty for not being able to breast feed my baby’. (Mother, 35, White, Breast cancer) ‘It took away a lot of the guilt my wife felt at not being able to fully breastfeed him and that really helped her.’ (Father, 40, White, Partner insufficient glandular tissue) Reducing feelings of failure Others described feeling like they had failed as a mother in not being able to breastfeed their baby, yet receiving DHM helped them process this belief, feeling like they were supporting their baby by being able to get them DHM. Again, this emotion was common even when women often had no choice due to complex health reasons. ‘I had the deepest urge to breastfeed my baby and I just couldn’t, my milk did not come in, no one can say why, receiving the donor milk made me feel like I wasn’t failing my baby by only formula feeding him.’ (Mother, 39, White, Absent milk supply) Helping women to process their situation Many of the women in the study had health complications that prevented them from being able to breastfeed. Some had not discovered these until after the birth or had not been told that they wouldn’t be able to breastfeed until late on in their pregnancy. The shock at not being able to feed their baby in the way they had hoped for and planned was clear with women finding it difficult to process their feelings about feeding their baby in a different way or how that fitted with their assumptions of how they would care for their baby. DHM appeared to play a role in reducing this. ‘Mentally helped me to come to terms with possibly having insufficient glandular tissue and prepared me for possibly not being to fully breast feed.’ (Mother, 33, White, low milk supply) Theme six: The emotional protection of being able to continue breastfeeding Looking specifically at mothers who were using DHM as a supplement whilst trying to establish their own milk supply, a common feeling was that using DHM in this way helped them to establish and continue breastfeeding. Many attributed this as helping them to continue as it felt beneficial to keep persevering when things were difficult as their baby had an exclusive human milk diet. She started putting on weight for the first time and moved from the 1st percentile to a healthier level of 9th percentile. It gave her the boost she needed to grow and breastfeed more efficiently, increasing my supply adequately. She is now a healthy 75th percentile baby and she is still exclusively breastfed while exploring solid foods. (Mother, 36, insufficient glandular tissue). (Mother, 40, Other, Faltering Growth) ‘Donor milk saved our breastfeeding relationship. Breastfeeding was so important to me for so many reasons and being able to breathe, knowing my babies had human milk to drink, I was able to undo the damage done by the hospital postnatal experience and relax into relactating for my twins’. (Mother, 38, White, Premature twins) The psychological benefits this offered women were significant. Many talked about DHM allowing them to continue with their feeding desires and plans and image of how they would care for their baby, describing the positive impacts of this many months after receiving DHM ‘I look back now to those early days and marvel at how far we have come. Those few feeds of donated milk gave me the strength to carry on with that punishing triple feeding routine and I am so, so grateful to be in this place still breastfeeding her now at 9 months. She’s had some health challenges due to her prematurity but I feel that I’m doing the best I can for her by breastfeeding her and to be honest I think that some days that’s all that’s preventing me from feeling like I failed her.’ [Mother, 37, Black, Premature baby] Theme seven: The impact of reactions of family and friends Finally, some parents in the study talked about how the reactions of their friends and family when they heard that they were using DHM affected their wellbeing. For some this was positive, but for others criticism or judgement made things more difficult. Positive, supportive reactions Some parents in the study experienced positive reactions from friends and family who were eager to find out more about DHM or had positive knowledge about the impact it could have. ‘I felt that in a very difficult circumstance (cancer treatment 3 weeks post delivery) I was heard, supported, encouraged. My family (parents) were relieved as well’. (Mother, 44, Other, Breast Cancer treatment) ‘My family are hugely grateful for the charity and didn’t know such an organisation existed until I had contacted the charity.’ (Mother, 35, White, Breast Cancer) Others simply knew how important DHM was to the parents and their support of them using it helped validate and encourage their decision. ‘My dad didn’t really get it but he knew how important it was to me and even drove miles to collect some milk one day. It meant so much to me that he had my back through this’ (Mother, 36, White, Medication issues) Notably, sometimes using DHM also stopped wider pressure to give formula milk supplements: ‘It stopped my wider family and friends telling me that it ‘wouldn’t hurt’ to just give her formula’. (Mother, 37, White, Premature baby) Negative, unsupported reactions Some parents experienced negative reactions, either from their partner or wider family. This made a difficult experience even more challenging, leading parents to feel unsupported and let down just when they needed others the most. ‘It was a bit of a taboo subject and I was criticised for wanting to give my baby donor milk, and this left me feeling isolated during a time when I needed my family’s support’. (Mother, 28, White, Faltering growth) ‘My partner didn’t understand at first and tried to suggest formula milk would be better and I found this very upsetting. He did come round but I feel like if he had known more about it at the start it would have been much easier for us all.’ (Mother, 29, Asian British Chinese, Premature baby) Discussion This study explored the experiences of parents who had received screened DHM from a milk bank for their baby and the impact that this had upon their wellbeing. It was clear that receiving DHM not only eased anxieties over infant health and developmental outcomes, particularly for premature infants or if there was a family history of illness or allergy, but impacted more broadly upon parental mental health. Mothers felt listened to, cared for and part of a connected community of women, and fathers often felt relieved at being able to play a role by ‘doing something’ by collecting the DHM. Notably receiving DHM allowed parents to meet their feeding goals regarding their baby having human milk, and this was reported to have a significant protective impact upon maternal mental health in particular. Building upon existing evidence of the significant cost savings of providing human milk to premature infants, 11 our findings highlight that extending DHM provision could play a potential preventative role in the significant health burden and cost implications of postnatal mental health issues 23 . Focusing on the impact of infant feeding experience upon maternal mental health, previous research has shown that mothers who are motivated to breastfeed can experience significant negative emotions of guilt, grief, and loss if they are unable to meet their breastfeeding goals 24 , putting them at an increased risk of postnatal depression 25 – 27 . This was echoed in our study; mothers talked about feeling devastated, anxious and heartbroken at the realisation they could not breastfeed or do so exclusively. For these motivated women this was more than feeling a little sad and needing to adapt; it was a grief reaction. As with many studies exploring breastfeeding difficulties, 28 , 29 guilt was a common and central emotion to not being able to breastfeed or do so exclusively, despite every mother in the study experiencing medical complications, with many working hard to build their supply. However, for many, being able to access DHM significantly reduced this guilt and grief. Our findings further extend our understanding of the complex interaction between infant feeding and mental health. We know that maternal anxiety and guilt related to not being able to breastfeed is based around concern for infant health and development. Receiving DHM was attributed to reducing these concerns, particularly when infants were premature or there was a family history of health complications. Mothers described the pride that they felt at managing to secure DHM for their baby despite complications, echoing the pride breastfeeding mothers, 30 or those expressing for their premature infants in the neonatal unit have previously described 31 . It also reflects findings of a US study exploring experiences of receiving DHM where mothers felt proud and empowered to be able to give their baby DHM 18 . It is therefore clear that this pride and reassurance is not only linked to the act of directly breastfeeding or expressing human milk, but also applies, although potentially sometimes at a lower level, when mothers have secured DHM for their baby. We raise the proviso of ‘sometimes at a lower level’ as some mothers in the study experienced conflicting emotions around another mother feeding their baby when they could not, which has been reflected in previous research 32 . Others expressed guilt over receiving DHM, fearing that other more vulnerable infants were more deserving. Such mixed emotions require specific exploration in a further study. Notably many mothers highlighted how receiving DHM helped them to process the information that they had a health issue or complication that prevented exclusive or partial breastfeeding. Experiencing significant breastfeeding difficulties can be a lonely experience, exacerbated by feelings of loss at the expectations of a nurturing relationship. It is stressful and has been described as a ‘constant fight’ to overcome difficulties 31 . DHM allowed mothers to step back from this ‘fight’ and start to recover. This reflects findings with mothers of premature infants who found that expressing their milk and being able to feed their baby helped them to heal from a traumatic 33 or premature 34 birth. It also fits into research which describes how breastfeeding mothers experiencing stress or mental health difficulties sometimes feel that they are managing to do ‘something right’ by breastfeeding 30 , 35 . Mothers may not be directly breastfeeding, but in sourcing human milk for their infant, they clearly felt they were playing a role in protecting and supporting their baby. Fathers in the study also highlighted how the experience of being able to practically play a role by arranging and collecting deliveries of DHM helped them to feel like they were doing something positive to help their partner and baby. This may support paternal mental health as previous research with fathers whose partner was experiencing breastfeeding difficulties, found that many reported feeling helpless and like a ‘spare part’, unable to make things better 36 , 37 . It may also play a role in further supporting breastfeeding. We know that mothers are more likely to feel empowered, confident and to continue breastfeeding if they feel supported by partners to breastfeed 38 . Further studies are required to explore if the practical support and participation of fathers around advocating for and collecting DHM helps mothers who are working to build their supply or to come to terms with not being able to breastfeed. Positive emotions related to receiving DHM were not simply about the milk that the baby was receiving. Part of the protective experience for mothers was feeling listened to and supported in their infant feeding plans. No one judged or laughed at their decision to give DHM or questioned its value – all experiences that breastfeeding women have reported 39 – 41 . Instead, mothers felt heard, validated, and reassured, key components in protecting maternal mental health 42 . Additionally, mothers had the experience of reaching out for support when experiencing a feeding difficulty and receiving the support they needed – a critical aspect of the relationship between breastfeeding and maternal mental health 43 , 44 . A lack of support to breastfeed and subsequently needing to stop prematurely can exacerbate breastfeeding grief and postnatal depression 25 – 27 . The experience of not receiving the support they presumed would occur due to heavy promotion of breastfeeding antenatally can leave mothers feeling let down, gaslit and angry 35 , 41 , 45 . Simply being listened to and having their wishes respected appeared to have a positive influence on maternal wellbeing separate from receiving the DHM for their baby. Related to this was the value mothers placed on being able to follow through with their infant feeding plans. Although they experienced a complex array of emotions at not being able to breastfeed fully (or fully at first), many valued their feeding decisions being respected and the option to be able to choose to use DHM over infant formula. The relationship women have with breastfeeding extends far beyond health impacts, including bodily autonomy, and cultural and religious beliefs 45 , 46 , 47 . Breastfeeding success can be closely tied to maternal identity and preferred way of mothering 48 , 49 . Our data suggest that this experience may also apply when being able to source DHM in the context of health barriers. Some mothers reported family and friends not understanding or valuing their decision to use DHM. Some were critical, leaving mothers feeling even more unsupported at a challenging time. Family attitudes to breastfeeding can be complex, with critical or inaccurate views affecting the support new mothers receive. These are often bound up in personal difficult experiences of feeding babies, with some feeling criticised when their own daughter chooses to feed in a different way 50 , 51 . Although research in this area has typically focused on breastfeeding, it is likely that similar concepts apply, alongside views around human milk as a potentially contaminated or sexual fluid 52 in contrast to carefully designed ‘scientific’ and ‘sanitised’ adverts of infant formula milk 53 may influence how some people react towards the concept of DHM. Further research needs to explore public perceptions and understanding of DHM and develop public health education programmes. Finally, a number of mothers in our study noted that receiving DHM helped them to establish breastfeeding. The literature examining whether DHM supplementation has any impact on continued breastfeeding rates over formula milk supplementation is limited. One review found that DHM increased the rates of any breastfeeding at discharge from hospital but had no effect on exclusive breastfeeding rates 54 . Another study retrospectively examined the effect of DHM as a feeding supplement instead of formula milk in a level 1 NICU on exclusive breastfeeding rates at 6 months. Comparing feeding outcomes at six months for 73 infants who received formula milk supplementation before the implementation to 49 infants who received DHM after, infants who received DHM were five-fold more likely to just be receiving breastmilk at six months old 55 . Our data supports preliminary explanations as to why DHM may protect the breastfeeding relationship more than formula supplementation. DHM enabled their baby to be exclusively human milk fed which increased motivation to continue this – more so than if formula supplementation had been introduced. This echoes findings in another study where mothers saw formula introduction as a more permanent change to their baby’s diet whereas DHM represented a short-term bridge to exclusive breastfeeding 17 . Additionally, some mothers commented that they felt that they needed to continue trying to establish their supply as other women had taken the time to express and donate their milk to support them. The study was limited in that the sample was self-selecting both in terms of participation and whether DHM was received. It is possible that parents who were already motivated to seek DHM and had a positive experience were more likely to complete the survey meaning that more negative or neutral experiences may not be included. Our decision to include fathers / partners in the research was also important as they may play a key role in DHM provision. However, only small numbers took part and care must be taken when extrapolating from these findings. Further research needs to measure prospectively any potential link between receiving DHM and anxiety and depression, considering the impact of being randomised to receive DHM or not. Our sample was also weighted towards older participants with higher levels of education; this represents a common limitation of survey research but also may reflect who is seeking out and using DHM 19 . In terms of ethnicity our sample is similar to the demographic representation in the UK but likely under-sampled parents from non-White backgrounds given a higher rate or premature birth amongst Black, Asian and Minority Ethnic groups 56 . Future studies should aim to draw comparisons between experiences from different ethnic groups. Conclusions To conclude, our data clearly shows that parents who have received DHM perceived that such support improved their mental health, made them feel listened to and cared for, and that their infant feeding wishes were respected. Receiving DHM and/or not needing to give their baby formula milk were considered to be protective for mental health and wellbeing by parents who were highly motivated for their baby to receive human milk. Given the significant personal, social and financial impact that postnatal depression has upon parents and communities, our research indicates a further reason to improve the availability of DHM. Declarations Ethics approval and consent to participate: Full ethical permission was gained from Swansea University College of Human and Health Sciences Research Ethics Committee. Participants gave informed consent and all aspects of the study were carried out in line with the declaration of Helsinki. Consent for publication: Not applicable. Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available to protect participant confidentiality but are available in an anonymised form from the corresponding author on reasonable request. Competing interests: AB is a trustee for the charity First Steps Nutrition Trust. NS is a cofounder and consultant for the Human Milk Foundation, a charity that operates the Hearts Milk Bank. Funding: None received. NS is a UKRI Future Leaders Fellow at Imperial College London (grant p76489), and UKRI funding supported the writing and publication of this manuscript. Authors' contributions: AB and NS were both responsible for study design, data analysis, draft writing and critical revisions. Acknowledgements: We thank the parents who took part in our study. References Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387:475-90. Altobelli E, Angeletti PM, Verrotti A, Petrocelli R. The impact of human milk on necrotizing enterocolitis: a systematic review and meta-analysis. Nutrients. 2020;12:1322. Lechner BE, Vohr BR. Neurodevelopmental outcomes of preterm infants fed human milk: a systematic review. Clin Perinatol. 2017;44:69-83. 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. Journal of Human Lactation. 2016;32:695-703. Boyd CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2007;92:F169-175. Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2014;4:CD002971. 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:CD002971. Arslanoglu S, Bertino E, Tonetto P, De Nisi G, Ambruzzi AM, Biasini A, et al. Guidelines for the establishment and operation of a donor human milk bank: Italian Association of Human Milk Banks Associazione Italiana Banche del Latte Umano Donato (AIBLUD: www. aiblud. org). J Matern Fetal Neonatal Med. 2010;23:1-20. Villamor-Martínez E, Pierro M, Cavallaro G, Mosca F, Kramer BW, Villamor E. Donor human milk protects against bronchopulmonary dysplasia: a systematic review and meta-analysis. Nutrients. 2018;10:238. Wight NE. Donor human milk for preterm infants. J Perinatol. 2001;21:249-54. Zanganeh M, Jordan M, Mistry H. A systematic review of economic evaluations for donor human milk versus standard feeding in infants. Matern Child Nutr. 2021:17:e13151. 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:S3-6. Perrin MT, Belfort MB, Hagadorn JI, McGrath JM, Taylor SN, Tosi LM, et al. The nutritional composition and energy content of donor human milk: a systematic review. Adv Nutr. 2020;11:960-70. Mondkar J, Chawla D, Sachdeva RC, Manerkar S, Shanbhag S, Khan A, et al. Impact of mother-baby friendly initiative plus approach on improving human milk feeding for neonates in hospital: a quality improvement before-and-after uncontrolled study. Eur J Pediatr. 2021;3. Kantorowska A, Wei JC, Cohen RS, Lawrence RA, Gould JB, Lee HC: Impact of donor milk availability on breast milk use and necrotizing enterocolitis rates. Pediatrics. 2016;137:e20153123. Wilson E, Edstedt Bonamy AK, Bonet M, Toome L, Rodrigues C, Howell EA et al. Room for improvement in breast milk feeding after very preterm birth in Europe: Results from the EPICE cohort. Matern Child Nutr. 1018;14:1. Kair LR, Flaherman VJ. Donor milk or formula: a qualitative study of postpartum mothers of healthy newborns. Journal of Human Lactation. 2017;33:710-6. McCloskey RJ, Karandikar S. Peer-to-peer human milk sharing: recipient mothers' motivations, stress, and postpartum mental health. Breastfeed Med. 2019;14:88-97. Bramer S, Boyle R, Weaver G, Shenker N. Use of donor human milk in nonhospitalized infants: an infant growth study. Matern Child Nutr. 2021;17:e13128. Sandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health. 2010;33:77-84. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101. Lincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New directions for program evaluation. 1986;1986:73-84. Gurung B, Jackson LJ, Monahan M, Butterworth R, Roberts TE. Identifying and assessing the benefits of interventions for postnatal depression: a systematic review of economic evaluations. BMC pregnancy and childbirth. 2018;18:1-8. Brown A. What do women lose if they are prevented from meeting their breastfeeding goals?. Clinical Lactation. 2018;9:200-7. Brown A, Rance J, Bennett P. Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. J Adv Nurs. 2016;72:273-82. Figueiredo B, Canário C, Field T. Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression. Psychol Med. 2014;44:927-36 Kendall-Tackett K. A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Int Breastfeed J. 2007;2:6. Asiodu IV, Waters CM, Dailey DE, Lyndon A. Infant feeding decision-making and the influences of social support persons among first-time African American mothers. Maternal and child health journal. 2017;21:863-72. Hanell L. The failing body: Narratives of breastfeeding troubles and shame. J Ling Anthropol. 2017;27:232-51. Shepherd L, Walbey C, Lovell B. The role of social-cognitive and emotional factors on exclusive breastfeeding duration. Journal of Human Lactation. 2017;33:606-13. Palmér L, Carlsson G, Mollberg M, Nyström M. Severe breastfeeding difficulties: Existential lostness as a mother—Women's lived experiences of initiating breastfeeding under severe difficulties. International journal of qualitative studies on health and well-being. 2012;7:10846. 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;32:95-102. Lööf-Johanson M, Foldevi M, Rudebeck CE. Breastfeeding as a specific value in women's lives: the experiences and decisions of breastfeeding women. Breastfeed Med. 2013;8:38-44. Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds: a key to “becoming a mother” and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med. 2006;62:70-80. Brown A. What do women really want? Lessons for breastfeeding promotion and education. Breastfeed Med. 2016;11:102-10. Brown A, Davies R. Fathers' experiences of supporting breastfeeding: challenges for breastfeeding promotion and education. Matern Child Nutr. 2014;10:510-26. Rempel LA, Rempel JK, Moore KC. Relationships between types of father breastfeeding support and breastfeeding outcomes. Matern Child Nutr. 2017;13:e12337. Srisopa P, Lucas R. Maternal Perception of Paternal Breastfeeding Support: A Secondary Qualitative Analysis. Midwifery. 2021 17:103067. Pedersen S. The good, the bad and the ‘good enough’ mother on the UK parenting forum Mumsnet. Women's Studies International Forum 2016;59:32-38. Regan S, Brown A. Experiences of online breastfeeding support: Support and reassurance versus judgement and misinformation. Matern Child Nutr. 2019;15:e12874. Fox R, McMullen S, Newburn M. UK women’s experiences of breastfeeding and additional breastfeeding support: a qualitative study of Baby Café services. BMC Pregnancy Childbirth. 2015;15:1-2. McCabe JE, Wickberg B, Deberg J, Davila RC, Segre LS. Listening Visits for maternal depression: a meta-analysis. Arch Womens Ment Health. 2021:24:595-603. McFadden A, Gavine A, Renfrew MJ, Wade A, Buchanan P, Taylor JL, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews. 2017;2:CD001141. Coates R, Ayers S, de Visser R. Women’s experiences of postnatal distress: a qualitative study. BMC Pregnancy Childbirth. 2014;14:1-4. Brown A. Why breastfeeding grief and trauma matter. Pinter & Martin Limited; 2019. Burns E, Fenwick J, Sheehan A, Schmied V. Mining for liquid gold: midwifery language and practices associated with early breastfeeding support. Matern Child Nutr. 2013;9:57-73. Hegney D, Fallon T, O’Brien ML. Against all odds: a retrospective case‐controlled study of women who experienced extraordinary breastfeeding problems. J Clin Nurs. 2008;17:1182-92. Demirci J, Caplan E, Murray N, Cohen S. “I just want to do everything right:” Primiparous women's accounts of early breastfeeding via an app-based diary. J Ped Health Care. 2018;32:163-72. Brown A, Lee M. An exploration of the attitudes and experiences of mothers in the United Kingdom who chose to breastfeed exclusively for 6 months postpartum. Breastfeed Med. 2011;6:197-204. Darwent KL, McInnes RJ, Swanson V. The Infant Feeding Genogram: a tool for exploring family infant feeding history and identifying support needs. BMC pregnancy and childbirth. 2016;16:1-0. Trickey H, Totelin LMV, Sanders J. ‘ Nain, Mam and Me: Historical artefacts as prompts for reminiscence, reflection and conversation about feeding babies. A qualitative development study ’. Research for All 2017;1:64-83 Foss KA. Marginalized Milk: “Extreme” Nursing, Milk Exchange, and Erotic Breastfeeding. In: Breastfeeding and Media 2017 (pp. 205-227). Palgrave Macmillan, Cham. Hastings G, Angus K, Eadie D, Hunt K. Selling second best: how infant formula marketing works. Globalization and Health. 2020;16:1-2. Williams T, Nair H, Simpson J, Embleton N. Use of donor human milk and maternal breastfeeding rates:a systematic review. J Hum Lact. 2016;32:212-20. Merjaneh N, Williams P, Inman S, Schumacher M, Ciurte A, Smotherman C, et al. The impact on the exclusive breastfeeding rate at 6 months of life of introducing supplementary donor milk into the level 1 newborn nursery. J Perinatol. 2020;40:1109-14. Li Y, Quigley MA, Macfarlane A, Jayaweera H, Kurinczuk JJ, Hollowell J. Ethnic differences in singleton preterm birth in England and Wales, 2006‐12: Analysis of national routinely collected data. Paediatric and perinatal epidemiology. Paediatr Perinat Epidemiol. 2019;33:449-58. Additional Declarations Competing interest reported. AB is a trustee for the charity First Steps Nutrition Trust. NS is a cofounder and consultant for the Human Milk Foundation, a charity that operates the Hearts Milk Bank. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 06 Feb, 2022 Reviews received at journal 23 Jan, 2022 Reviewers agreed at journal 20 Jan, 2022 Reviewers agreed at journal 08 Jan, 2022 Reviewers invited by journal 01 Jan, 2022 Editor assigned by journal 01 Jan, 2022 Editor invited by journal 29 Dec, 2021 Submission checks completed at journal 29 Dec, 2021 First submitted to journal 13 Dec, 2021 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-1167440","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":73045874,"identity":"dc38fa94-d9f8-43b5-a469-c5e40f3e9e37","order_by":0,"name":"Amy Brown","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYJACZjDJ3oAimECEFp4DJGuRQFWEWwt/A/MB5sI9NonbJZ8/k/i5o04OKPLwA2NbGk4tEgfYEphnPEtL3Dk7x0yy98xhY6CIsQRjWw5uVx3gMWDmOXA4d8PtHLYbvG0HEhsOMJgxMLZV4NQhf4D/A0TLzePPbv5tq6uff4D9G14tBgd4GCBabjCY3eZtY04AioBswe0ww8NsBodnHEir33Amx/y3bNthw42HeYolEs7h9r7c8eaHjwsO2BgbHD/+2PBtW5283PH2jR8+lCXj9j4wUg5giBCIyFEwCkbBKBgFhAAAhgVU+GFkkpEAAAAASUVORK5CYII=","orcid":"","institution":"Swansea University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Brown","suffix":""},{"id":73045875,"identity":"5702c27b-4301-4659-8e73-9c0e389a15ee","order_by":1,"name":"Natalie Shenker","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"","lastName":"Shenker","suffix":""}],"badges":[],"createdAt":"2021-12-13 17:14:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1167440/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1167440/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":16881750,"identity":"db55a67a-4a38-447f-9d19-1ed6823f6577","added_by":"auto","created_at":"2021-12-30 19:02:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":400391,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1167440/v1/0d016ab1-501f-4e7e-988f-235497ef839f.pdf"}],"financialInterests":"Competing interest reported. AB is a trustee for the charity First Steps Nutrition Trust. NS is a cofounder and consultant for the Human Milk Foundation, a charity that operates the Hearts Milk Bank.","formattedTitle":"\u003cp\u003eReceiving Screened Donor Human Milk for Their Infant Supports Parental Wellbeing: a Mixed-methods Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHuman milk is established as protecting infant health\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, but is particularly important in protecting the health and development of premature infants. Premature infants who receive human milk are less likely to develop life-threatening conditions such as necrotising enterocolitis [NEC]\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, late-onset sepsis, and have better cognitive development\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. However, as a result of prematurity, mother-infant separation, and birth trauma, mothers of the smallest and sickest infants can struggle to produce or express enough milk for their baby\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eFor this reason, human milk banks (HMBs) were created to enable other mothers to donate their breastmilk. Donor human milk (DHM) reduces the incidence of NEC\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, sepsis,\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e and bronchopulmonary dysplasia\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Infants fed with DHM rather than infant formula where there is a shortfall of maternal milk also tolerate full feeds more rapidly and leave hospital sooner\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, with likely consequent cost-effectiveness in the hospital setting\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. While research has typically focused on the health impacts in infants receiving DHM\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e or DHM content and variability\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, increasing data from international sources shows a beneficial effect on maternal breastfeeding rates when DHM is available in the context of optimal lactation support\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThere is a paucity of evidence regarding the experiences of families whose infants receive DHM and its impact on maternal mental health. In the USA, an interview study with 30 mothers of late pre-term and term babies who were using supplemental DHM identified that mothers perceived it as better for infant health, which reduced their anxiety\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Another US study that interviewed 50 mothers who received human milk via informal mother to mother sharing reported decreased stress and symptoms of postnatal anxiety and depression, again because they felt that DHM protected their baby. Some felt pride at being able to source milk for their baby, although others found the process stressful\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. In 2019 a service evaluation of the Hearts Milk Bank, a new non-profit HMB in the UK, identified recurrent reports from parents who indicated receiving DHM for their baby had reduced their symptoms of anxiety and depression post-partum\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. This study sought to add to this literature by conducting a larger mixed methods study examining the experiences of having received DHM upon parental mental health in a larger sample in the UK.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section3\"\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eParents in the UK with a baby aged 0 \u0026ndash; 12 months who had received screened DHM from a milk bank participated in this study. This time period was selected to allow for sufficient participants to have received DHM and be able to reflect on their experiences but to reduce any risk of recall bias due to significant time passing since they received DHM. The decision was made to include both mothers and fathers / partners in the study because often fathers/ partners are instrumental in organising and collecting DHM. They may also be sourcing milk for an adopted infant or be caring solely for their infant if the mother is critically unwell or has died. STROBE guidelines were followed and full ethical permission for the study was gained from Swansea University Research Ethics Committee. Participants gave informed consent and all aspects of the study were carried out in line with the declaration of Helsinki. All participants gave informed consent prior to completing the survey.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\n\u003ch2\u003eMeasures\u003c/h2\u003e\n\u003cp\u003eParticipants completed an online questionnaire containing both closed and open questions, hosted by Qualtrics. The questionnaire included:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eDemographic details (maternal age, education, ethnicity)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eDetails of the infant that they received DHM for (age, sex, gestation at birth)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCurrent milk feeding status of their infant (breastfeeding duration and exclusivity, formula use, DHM use, reasons for stopping breastfeeding if relevant)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eDetails of DHM use (duration, exclusivity, approximate volume received, milk bank used)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e5-point likert scale items examining perceived impact of DHM upon infant health and development, own wellbeing and family wellbeing [Strongly agree \u0026ndash; strongly disagree]\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eOpen ended questions exploring experience of receiving DHM and perceived impacts upon infant health and development, own wellbeing and family wellbeing (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eOpen ended questions exploring experiences of receiving donor human milk\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Can you tell us a little about what motivated you to want donor milk for your baby?\u003c/p\u003e\n\u003cp\u003e\u0026bull; How did receiving donor milk make you feel?\u003c/p\u003e\n\u003cp\u003e\u0026bull; If you were also breastfeeding your baby, how did receiving donor milk affect your experience of breastfeeding?\u003c/p\u003e\n\u003cp\u003e\u0026bull; What impact do you feel that donor milk had for your baby?\u003c/p\u003e\n\u003cp\u003e\u0026bull; What impact do you feel that receiving donor milk had for you and your wider family?\u003c/p\u003e\n\u003cp\u003e\u0026bull; How did your experience of donor milk fit with your expectations of receiving donor milk? Was it better? Different? More challenging than expected?\u003c/p\u003e\n\u003cp\u003e\u0026bull; Finally, do you have any further comments on the experience of receiving donor milk?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\n\u003ch2\u003eProcedure\u003c/h2\u003e\n\u003cp\u003eData were collected for six months from June \u0026ndash; December 2020. Adverts containing brief details of the study and inclusion criteria were placed on social media with encouragement for breastfeeding, milk banking and parenting organisations to share the post. Adverts contained a link to the study information sheet for further information followed by consent questions if interested participants wanted to continue. UK residence was confirmed by participants having a UK postcode. Only when all consent items were agreed did the full questionnaire load. Once completed a debrief statement was given, explaining the study, thanking them for participation, and giving them contact details for support organisations if needed.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eQuantitative data were analysed using SPSS version 27 to compute descriptive statistics regarding perceptions and experience of DHM use. A thematic analysis was conducted on qualitative data from the open-ended questions using a simple descriptive analysis\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The first researcher immersed themselves in the data, reading through responses from each participant and across questions for all participants. Next responses were read and re-read to identify smaller themes. These smaller themes were then grouped into larger subthemes\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. To enhance trustworthiness of the data\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, initial coding was completed by one researcher, with a second reviewing themes and subthemes. Where disagreement occurred, themes were discussed until agreed. An example of the overall process of how the analysis moved from raw data to subtheme, to theme is shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eShowing analysis process from raw data to theme\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRaw data\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSubtheme\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSubtheme description\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTheme\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTheme description\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It\u0026rsquo;s hard to put in words how it felt to know I could still provide breast milk for the baby...it felt like an army of invisible mothers looking after us and felt very emotional and still does when I think back to it.\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFeeling connected to other mothers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWomen felt supported by and connected to a network of other women who had been kind enough to donate their milk to strangers.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFeeling supported and care for\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe experience of receiving DHM from a milk bank helped mothers feel that someone was listening to them, seeing their desire to give their baby DHM and supporting them.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants remained in the study if they completed the Likert scales examining their perceived impact of DHM. However, for the open-ended questions some participants [n = 5] gave short responses (providing only a few words over all open-ended questions), wrote that they were \u0026lsquo;unsure\u0026rsquo; [n = 4] or left the open-ended questions blank [n = 3]. This left 95 participants (92 mothers and 3 fathers) who contributed to the qualitative analysis. Responses given were typically in depth and often crossed these themes and subthemes within one response (see Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e for a typical example response).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eExample of typical depth and length of open-ended response\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I cannot quite put into words the sheer relief that I felt when I learned that we would be able to access 3 litres of donor milk from the Hearts Milk Bank. We had been struggling with latching my tongue-tied baby for 3 weeks and she still hadn\u0026rsquo;t regained her birth weight. My partner has severe allergies which have affected him throughout his entire life. After 3 weeks of inefficient feeding my supply was impacted and my baby was hungry. I did not want to give her formula if at all avoidable as we suspected that my partner\u0026rsquo;s issues stem from being given formula as a first feed following his birth. Learning that we could access this donor milk to help bridge the gap between my supply and Ivy\u0026rsquo;s hunger while we worked to rebuild it (via expressing and taking supplements for 3 more months) was a feeling akin to having held my breath for 3 weeks and finally being able to breathe again. I broke down on the phone to [milk bank lead] who confirmed to us we would be able to have some milk. I was overjoyed overwhelmed with relief. I felt supported and justified finally in my desire to not have to resort to formula. I felt grateful and that somebody finally understood our desires and struggle\u0026rsquo;. (Mother)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOne hundred and seven participants completed the survey including 102 mothers and five fathers. Mean age of participants was 32.38 (SD: 5.80) with a range from 19 to 47 years. DHM was received for 115 infants (eight sets of twins) of which 48 (44.8%) were male. Age of infant at birth range from 24 to 43 weeks with a mean gestation of 33.1 weeks (SD: 4.64 weeks). Further demographic details are shown in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eParticipant demographic background.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIndicator\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eAge (yr)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026le;\u003c/span\u003e 19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 \u0026ndash; 24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25 \u0026ndash; 29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 \u0026ndash; 34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026ge;\u003c/span\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eEducation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSchool\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCollege\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigher\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e48.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePostgraduate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarital status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003cp\u003eCohabiting\u003c/p\u003e\n\u003cp\u003eSingle\u003c/p\u003e\n\u003cp\u003eWidowed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e61\u003c/p\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e57.0\u003c/p\u003e\n\u003cp\u003e37.4\u003c/p\u003e\n\u003cp\u003e4.7\u003c/p\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eEthnicity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhite\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e85.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGypsy / Traveller / Roma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAsian or Asian British (Bangladeshi, Indian, Pakistani)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAsian or Asian British (Chinese)\u003c/p\u003e\n\u003cp\u003eBlack or Black British\u003c/p\u003e\n\u003cp\u003eMixed or multiple\u003c/p\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.9\u003c/p\u003e\n\u003cp\u003e2.7\u003c/p\u003e\n\u003cp\u003e4.7\u003c/p\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eParity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFirst baby / first multiple birth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSecond or more\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e44.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eCountry\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEngland\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e80.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eScotland\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWales\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNorthern Ireland\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eReceiving donor human milk\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eMilk was received from nine different HMBs, including seven in England, one in Scotland and one in Northern Ireland (with 8.4% (n = 9 participants) not sure which milk bank provided their DHM). The majority of infants started receiving DHM in the first days of life. Overall, 35 infants (32.7%) received it from their day of birth, 40 (56.1%) by day three, and 95 (88.8%) by the end of the first week. However, age at starting DHM ranged from birth to 4 months old.\u003c/p\u003e\n\u003cp\u003eParticipants were asked the duration that their infant received DHM exclusively (receiving only DHM feeds) and non-exclusively (DHM alongside own milk or formula). The majority of infants received exclusive DHM at first, but for less than a week (n = 90, 84.1%). The majority of infants then went on to receive DHM alongside others milk for up to a week (n = 91, 85.0%). However, some infants received DHM for an extended period (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDuration of DHM received.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDuration\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eExclusive DHM\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAlongside other milk\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 - 7 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 \u0026ndash; 14 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15 \u0026ndash; 21 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 \u0026ndash; 28 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 - 35 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36 \u0026ndash; 42 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 \u0026ndash; 49 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50 \u0026ndash; 56 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57 \u0026ndash; 63 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64 \u0026ndash; 70 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen asked to estimate how much donor milk they received overall 59.8% (n = 64) provided an estimate with the remainder unsure. This ranged from less than 100ml spread across supplemental feeds to up to 70 litres. However, the majority of infants (n = 50, 76.6%) received 5 litres or less.\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003ePerceived impact of donor milk\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were asked to rate the impact they felt receiving DHM had upon their infant and family (5-point likert scale from very positive to very negative). Participants perceived a very positive or positive impact on their baby for infant health (98.1%, n = 104), infant development (96.2%, n = 101), own mental health (96.2%, n = 101), own physical health (86.8%, n = 92) and family\u0026rsquo;s wellbeing (89.6%, n = 85). One participant in each case rated each aspect as having a negative impact with the remainder neutral.\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eExploring experiences of receiving donor milk\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were asked a series of open-ended questions exploring their experiences of receiving donor human milk. A thematic analysis identified seven themes, consisting of 16 subthemes overall. Examples of quotes are given below, with details of participant: parent, age, ethnicity, and where provided details of breastfeeding complication).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme one: Relief that their baby was receiving DHM for health reasons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA central theme to emerge was the perceived impact parents felt that receiving DHM had on their infant\u0026rsquo;s health and development and the subsequent impact that this had upon parental wellbeing. Parents believed that their infant\u0026rsquo;s immune system was supported, alongside reassurance for those who were worried about family history of allergy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It brings me great comfort knowing that I was optimising the amount of breastmilk she received. I genuinely believe that her immune system is great because she received different sources of antibodies on top of the antibodies I gave her.\u0026rsquo; (Mother, 28, White, Low milk supply)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;We have so many allergies between us and we were worried about her being so tiny and the effect that formula might have so we were very relieved to be able to supplement with DHM instead of formula. It helped reduce our anxiety and stress at a difficult time.\u0026rsquo; (Father, 42, White, Premature baby).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme two: Feeling supported and cared for\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe process of receiving DHM did not only affect parents in relation to feelings around how their baby was fed, but also helped them to feel cared for and supported, often at a very challenging point in time. Parents experienced this in a number of ways:\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eFeeling listened to\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eMany women talked about feeling listened to and respected in relation to how they wanted to feed their baby. It wasn\u0026rsquo;t just that they were given DHM but that someone asked them questions, listened to their story and saw how much they valued giving their baby DHM.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I expected to be laughed at to be honest but the woman I spoke to on the phone was just amazing. She was so kind and listened to how I felt and was so understanding and it made a real difference to my concerns.\u0026rsquo; (Mother, 41, White, Low milk supply).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eFeeling cared for\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eParents also felt cared for at a difficult time. Typically, families were in late pregnancy or the early days of having a baby when they were told they needed to supplement their baby or would not be able to breastfeed. They already felt vulnerable and exhausted, yet someone was there helping and caring for them\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I felt supported and like someone cared for me and my baby following diagnosed low supply.\u0026rsquo; (Mother, 36, White, Insufficient glandular tissue)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eFeeling supported by and connected to other mothers\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eOthers felt supported by a wider community of breastfeeding mothers who were donating their milk to strangers. Women felt supported by people they had never met and overwhelmed that someone they did not know could be so kind.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It\u0026rsquo;s hard to put in words how it felt to know I could still provide breast milk for the baby...it felt like an army of invisible mothers looking after us and felt very emotional and still does when I think back to it.\u0026rsquo; (Mother, 37)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNotably, this feeling of connection and gratitude to other women helped encourage some mothers to carry on expressing their own milk and trying to build their supply. They felt that others had stepped up to support them without even knowing them and that they owed it to the community to keep trying.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I found the triple feeding in particular really difficult but then I thought about the women who had taken the time to donate their milk and all that entails and it motivated me to keep trying. It felt like they were supporting me in this even though we had never met.\u0026rsquo; (Mother, 26, Black British, Faltering growth)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome mothers in the study then talked about the circle of going on to provide DHM themselves, feeling grateful of the opportunity to help others in their situation and that they were \u0026lsquo;paying back\u0026rsquo; the kindness of others.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;As soon as we were settled and feeding well I started to build up a stash of my own milk to donate back and it made me feel so good knowing it would likely go to a mum just like me who was stressed and desperate for help and I could play a part in changing all of that.\u0026rsquo; (Mother, 28, Black, Premature baby)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme three: Reducing the pressure in the early days \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany participants talked about how receiving DHM made the intense days after a birth (which was often premature or traumatic) easier. DHM reduced pressure regarding providing expressed milk, increased bonding and supported family relationships.\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eReducing pressure to provide expressed milk / build supply\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eSome women in the study were experiencing breastmilk supply difficulties and needed to supplement. Often women in this situation were trying to express milk for a premature baby who could not feed directly or were on a triple feeding plan whereby they breastfed their baby, topped up their baby with previously expressed milk and then tried to express more milk again. Although this can help build milk supply more quickly, it can feel exhausting for the mother. Receiving DHM in these circumstances helped reduce the pressure on mothers as they knew that their baby would be fed even if expressing did not go well that day.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I was so exhausted from trying to care for her and feed her and express. Just those few feeds of donor milk meant the pressure reduced and I could have a break from the ward for a bit. I think it made all the difference as allowed my stress to come down and for me to catch up on a bit of sleep. I think without that I might have given up breastfeeding altogether but that space, that physical and emotional space that donor milk allowed probably is a big part of why we\u0026rsquo;re still feeding now.\u0026rsquo; (Mother, 32, White, Premature baby).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eEnabling bonding\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eLinked to the reduction in pressure to produce sufficient breastmilk for their baby, some mothers described how this enabled them to take a step back and start to properly bond with their baby. It removed the stress from the relationship and feeding experience, allowing more positive interactions with their baby that weren\u0026rsquo;t focussed on attempting to produce more milk.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I think it helped us to bond better. Once I was less stressed and obsessed with making sure he just had my milk it felt as if everything eased between us?\u0026rsquo; (Mother, 34, Asian Chinese, Premature baby)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eSupporting family relationships\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eRelated to taking the pressure off needing to provide sufficient breastmilk themselves, the consequence of this reduced stress and pressure rippled out into the broader experience of early parenting, the transition to motherhood / fatherhood and family relationships. Mothers in particular felt that they could focus some of their attention on other children and felt less tense around their partner.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Reduced stress for all family as I was not stressing about not being able to provide the milk\u0026rsquo;. (Mother, 33, White, insufficient glandular tissue)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I was a better mum for it, my husband benefitted from this and we felt stronger and united in the parenting journey\u0026rsquo;. (Mother, 47, White, HIV positive)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eEnabling partners to play a role\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eSome mothers accessed DHM direct from the hospital when they were staying on the neonatal unit. However, others sourced DHM from milk banks who were able to provide some DHM to the community. In these cases DHM needed to be organised and collected. Although this could sometimes add an additional layer of stress, a number of parents in the study highlighted how it enabled the father / partner to be able to practically do something and feel like they were contributing to their baby being fed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I was able to go and collect the milk for our baby and that really helped me feel like I was doing something and that I was able to look after my partner in a way because she was very distraught. It also gave me something practical to think about and do rather than worrying about them both all the time.\u0026rsquo; (Father, 38, White. Premature baby).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme four: Supporting preferred feeding choices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnother central theme was the impact that receiving DHM had upon mothers (and sometimes partners) feeding plans and preferences. By the nature of this sample breastfeeding and receiving human milk was obviously very important to parents and having the option to be able to give their baby DHM played an important role in wellbeing, eliciting a whole host of emotions. These emotions typically split two ways: emotions at being able to provide DHM and emotions at being able to provide DHM.\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eOpportunity to use DHM\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eThe positive emotional experience of having the opportunity to give their baby DHM, sometimes enabling their baby to have a fully human milk diet, or sometimes in combination with formula milk was clear. Women used words such as feeling \u0026lsquo;\u003cem\u003egrateful\u0026rsquo;\u003c/em\u003e, \u0026lsquo;\u003cem\u003erelieved\u0026rsquo;\u003c/em\u003e, \u0026lsquo;\u003cem\u003eproud\u0026rsquo;\u003c/em\u003e and \u0026lsquo;\u003cem\u003eempowered\u0026rsquo;\u003c/em\u003e at being able to give their baby DHM.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It reduced any complicated feelings of guilt, it provided peace of mind, it made me feel happy and proud\u0026rsquo;. (Mother, 35, White, Double mastectomy)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe strength and depth of this relief was clear from many of the responses. Women didn\u0026rsquo;t simply feel a bit happier, but rather that their mental health was protected.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I was devastated when I realised I wasn\u0026rsquo;t going to produce enough milk myself for her and this felt like a genuine lifeline, that someone was pulling me out of a very dark place. I will always be so grateful to the support and kindness we received.\u0026rsquo; (Mother, 29, Asian British Pakistani, Low milk supply)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eOpportunity to avoid giving formula milk\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eConversely many women described their relief and gratitude at not needing to use formula milk when this was not part of their feeding plan.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I can say my daughter has been exclusively breastfed - my son had about 40 ml of formula when he was born then breastfed until 3 but in my head I could never say he was exclusively breastfed all the way through and that stuck with me. I didn\u0026rsquo;t want that again. My values are very much against using formula if there is human milk available and I am so glad that we were able to access this. I would have been so unhappy if that first week had been formula top ups every 3 hours as it just a would have felt to me like putting something in my baby which I don\u0026rsquo;t believe in. \u0026rsquo; (Mother, 34, Low milk supply)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConflicted and mixed emotions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHowever, although DHM allowed parents to feed their baby in the way they wanted, many did feel conflicted over using it. This was either in relation to not being able to exclusively breastfeed themselves, or feeling torn at another mother providing the milk for their baby. This sometimes compounded feelings of guilt that they weren\u0026rsquo;t providing milk for their baby directly themselves.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I felt guilty that it wasn\u0026rsquo;t my milk being given but grateful to be able to give breast milk rather than formula.\u0026rsquo; (Mother, 28, White, Premature baby)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eGuilt at receiving DHM\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eOne challenging emotion experienced amongst some mothers was the guilt at receiving DHM for their baby, believing that it might be taken away from a more vulnerable baby. Some felt that they needed to justify why they were using it to others around them and tell people that they were trying to increase their milk supply to feel deserving of receiving it.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo; [I felt] guilty for taking donor milk for my baby when more needy prem babies might miss out because we took the milk. I felt a constant need to explain to everyone all the things I was trying to get my supply up after my milk didn\u0026rsquo;t come in to justify having some donor milk to keep us going\u0026rsquo;. (Mother, 36, White, Tongue tie \u0026amp; latch issues)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme five: Alleviating complex emotions at not being able to breastfeed\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome mothers in the survey were using DHM to top up their own milk supply, sometimes due to having insufficient glandular tissue and therefore having a reduced supply or whilst waiting for their own milk supply to fully develop. Others were unable to breastfeed for health reasons and had sourced typically a small amount of DHM for their baby for the early weeks of life. The depth of emotion about how women felt at not being able to breastfeed or needing to supplement their baby was clear. However, receiving DHM supported maternal mental health in a number of ways.\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eReducing feelings of guilt\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eMany women talked about the guilt they felt at not being able to breastfeed their baby even though in every case described there was a physiological reason why women could not produce sufficient milk or breastfeeding was contraindicated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;[I felt] so grateful that I could give my baby the best start in life, humbled that women would donate their precious milk to people like me and less guilty for not being able to breast feed my baby\u0026rsquo;. (Mother, 35, White, Breast cancer)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It took away a lot of the guilt my wife felt at not being able to fully breastfeed him and that really helped her.\u0026rsquo; (Father, 40, White, Partner insufficient glandular tissue)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eReducing feelings of failure\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eOthers described feeling like they had failed as a mother in not being able to breastfeed their baby, yet receiving DHM helped them process this belief, feeling like they were supporting their baby by being able to get them DHM. Again, this emotion was common even when women often had no choice due to complex health reasons.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I had the deepest urge to breastfeed my baby and I just couldn\u0026rsquo;t, my milk did not come in, no one can say why, receiving the donor milk made me feel like I wasn\u0026rsquo;t failing my baby by only formula feeding him.\u0026rsquo; (Mother, 39, White, Absent milk supply)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eHelping women to process their situation\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eMany of the women in the study had health complications that prevented them from being able to breastfeed. Some had not discovered these until after the birth or had not been told that they wouldn\u0026rsquo;t be able to breastfeed until late on in their pregnancy. The shock at not being able to feed their baby in the way they had hoped for and planned was clear with women finding it difficult to process their feelings about feeding their baby in a different way or how that fitted with their assumptions of how they would care for their baby. DHM appeared to play a role in reducing this.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Mentally helped me to come to terms with possibly having insufficient glandular tissue and prepared me for possibly not being to fully breast feed.\u0026rsquo; (Mother, 33, White, low milk supply)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme six: The emotional protection of being able to continue breastfeeding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLooking specifically at mothers who were using DHM as a supplement whilst trying to establish their own milk supply, a common feeling was that using DHM in this way helped them to establish and continue breastfeeding. Many attributed this as helping them to continue as it felt beneficial to keep persevering when things were difficult as their baby had an exclusive human milk diet.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eShe started putting on weight for the first time and moved from the 1st percentile to a healthier level of 9th percentile. It gave her the boost she needed to grow and breastfeed more efficiently, increasing my supply adequately. She is now a healthy 75th percentile baby and she is still exclusively breastfed while exploring solid foods. (Mother, 36, insufficient glandular tissue). (Mother, 40, Other, Faltering Growth)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Donor milk saved our breastfeeding relationship. Breastfeeding was so important to me for so many reasons and being able to breathe, knowing my babies had human milk to drink, I was able to undo the damage done by the hospital postnatal experience and relax into relactating for my twins\u0026rsquo;. (Mother, 38, White, Premature twins)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe psychological benefits this offered women were significant. Many talked about DHM allowing them to continue with their feeding desires and plans and image of how they would care for their baby, describing the positive impacts of this many months after receiving DHM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I look back now to those early days and marvel at how far we have come. Those few feeds of donated milk gave me the strength to carry on with that punishing triple feeding routine and I am so, so grateful to be in this place still breastfeeding her now at 9 months. She\u0026rsquo;s had some health challenges due to her prematurity but I feel that I\u0026rsquo;m doing the best I can for her by breastfeeding her and to be honest I think that some days that\u0026rsquo;s all that\u0026rsquo;s preventing me from feeling like I failed her.\u0026rsquo; [Mother, 37, Black, Premature baby]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme seven: The impact of reactions of family and friends\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinally, some parents in the study talked about how the reactions of their friends and family when they heard that they were using DHM affected their wellbeing. For some this was positive, but for others criticism or judgement made things more difficult.\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003ePositive, supportive reactions\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eSome parents in the study experienced positive reactions from friends and family who were eager to find out more about DHM or had positive knowledge about the impact it could have.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I felt that in a very difficult circumstance (cancer treatment 3 weeks post delivery) I was heard, supported, encouraged. My family (parents) were relieved as well\u0026rsquo;. (Mother, 44, Other, Breast Cancer treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;My family are hugely grateful for the charity and didn\u0026rsquo;t know such an organisation existed until I had contacted the charity.\u0026rsquo; (Mother, 35, White, Breast Cancer)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOthers simply knew how important DHM was to the parents and their support of them using it helped validate and encourage their decision.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;My dad didn\u0026rsquo;t really get it but he knew how important it was to me and even drove miles to collect some milk one day. It meant so much to me that he had my back through this\u0026rsquo; (Mother, 36, White, Medication issues)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNotably, sometimes using DHM also stopped wider pressure to give formula milk supplements:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It stopped my wider family and friends telling me that it \u0026lsquo;wouldn\u0026rsquo;t hurt\u0026rsquo; to just give her formula\u0026rsquo;. (Mother, 37, White, Premature baby)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNegative, unsupported reactions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome parents experienced negative reactions, either from their partner or wider family. This made a difficult experience even more challenging, leading parents to feel unsupported and let down just when they needed others the most.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It was a bit of a taboo subject and I was criticised for wanting to give my baby donor milk, and this left me feeling isolated during a time when I needed my family\u0026rsquo;s support\u0026rsquo;. (Mother, 28, White, Faltering growth)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;My partner didn\u0026rsquo;t understand at first and tried to suggest formula milk would be better and I found this very upsetting. He did come round but I feel like if he had known more about it at the start it would have been much easier for us all.\u0026rsquo; (Mother, 29, Asian British Chinese, Premature baby)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the experiences of parents who had received screened DHM from a milk bank for their baby and the impact that this had upon their wellbeing. It was clear that receiving DHM not only eased anxieties over infant health and developmental outcomes, particularly for premature infants or if there was a family history of illness or allergy, but impacted more broadly upon parental mental health. Mothers felt listened to, cared for and part of a connected community of women, and fathers often felt relieved at being able to play a role by \u0026lsquo;doing something\u0026rsquo; by collecting the DHM. Notably receiving DHM allowed parents to meet their feeding goals regarding their baby having human milk, and this was reported to have a significant protective impact upon maternal mental health in particular. Building upon existing evidence of the significant cost savings of providing human milk to premature infants,\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e our findings highlight that extending DHM provision could play a potential preventative role in the significant health burden and cost implications of postnatal mental health issues\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eFocusing on the impact of infant feeding experience upon maternal mental health, previous\u0026nbsp;research has shown that mothers who are motivated to breastfeed can experience significant negative emotions of guilt, grief, and loss if they are unable to meet their breastfeeding goals\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, putting them at an increased risk of postnatal depression\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. This was echoed in our study; mothers talked about feeling devastated, anxious and heartbroken at the realisation they could not breastfeed or do so exclusively. For these motivated women this was more than feeling a little sad and needing to adapt; it was a grief reaction. As with many studies exploring breastfeeding difficulties,\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e guilt was a common and central emotion to not being able to breastfeed or do so exclusively, despite every mother in the study experiencing medical complications, with many working hard to build their supply. However, for many, being able to access DHM significantly reduced this guilt and grief.\u003c/p\u003e\n\u003cp\u003eOur findings further extend our understanding of the complex interaction between infant feeding and mental health. We know that maternal anxiety and guilt related to not being able to breastfeed is based around concern for infant health and development. Receiving DHM was attributed to reducing these concerns, particularly when infants were premature or there was a family history of health complications. Mothers described the pride that they felt at managing to secure DHM for their baby despite complications, echoing the pride breastfeeding mothers,\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e or those expressing for their premature infants in the neonatal unit have previously described\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. It also reflects findings of a US study exploring experiences of receiving DHM where mothers felt proud and empowered to be able to give their baby DHM\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIt is therefore clear that this pride and reassurance is not only linked to the act of directly breastfeeding or expressing human milk, but also applies, although potentially sometimes at a lower level, when mothers have secured DHM for their baby. We raise the proviso of \u0026lsquo;sometimes at a lower level\u0026rsquo; as some mothers in the study experienced conflicting emotions around another mother feeding their baby when they could not, which has been reflected in previous research\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Others expressed guilt over receiving DHM, fearing that other more vulnerable infants were more deserving. Such mixed emotions require specific exploration in a further study.\u003c/p\u003e\n\u003cp\u003eNotably many mothers highlighted how receiving DHM helped them to process the information that they had a health issue or complication that prevented exclusive or partial breastfeeding. Experiencing significant breastfeeding difficulties can be a lonely experience, exacerbated by feelings of loss at the expectations of a nurturing relationship. It is stressful and has been described as a \u0026lsquo;constant fight\u0026rsquo; to overcome difficulties\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. DHM allowed mothers to step back from this \u0026lsquo;fight\u0026rsquo; and start to recover. This reflects findings with mothers of premature infants who found that expressing their milk and being able to feed their baby helped them to heal from a traumatic\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e or premature\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e birth. It also fits into research which describes how breastfeeding mothers experiencing stress or mental health difficulties sometimes feel that they are managing to do \u0026lsquo;something right\u0026rsquo; by breastfeeding\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Mothers may not be directly breastfeeding, but in sourcing human milk for their infant, they clearly felt they were playing a role in protecting and supporting their baby.\u003c/p\u003e\n\u003cp\u003eFathers in the study also highlighted how the experience of being able to practically play a role by arranging and collecting deliveries of DHM helped them to feel like they were doing something positive to help their partner and baby. This may support paternal mental health as previous research with fathers whose partner was experiencing breastfeeding difficulties, found that many reported feeling helpless and like a \u0026lsquo;spare part\u0026rsquo;, unable to make things better\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. It may also play a role in further supporting breastfeeding. We know that mothers are more likely to feel empowered, confident and to continue breastfeeding if they feel supported by partners to breastfeed\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. Further studies are required to explore if the practical support and participation of fathers around advocating for and collecting DHM helps mothers who are working to build their supply or to come to terms with not being able to breastfeed.\u003c/p\u003e\n\u003cp\u003ePositive emotions related to receiving DHM were not simply about the milk that the baby was receiving. Part of the protective experience for mothers was feeling listened to and supported in their infant feeding plans. No one judged or laughed at their decision to give DHM or questioned its value \u0026ndash; all experiences that breastfeeding women have reported\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Instead, mothers felt heard, validated, and reassured, key components in protecting maternal mental health\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAdditionally, mothers had the experience of reaching out for support when experiencing a feeding difficulty and receiving the support they needed \u0026ndash; a critical aspect of the relationship between breastfeeding and maternal mental health\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. A lack of support to breastfeed and subsequently needing to stop prematurely can exacerbate breastfeeding grief and postnatal depression\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. The experience of not receiving the support they presumed would occur due to heavy promotion of breastfeeding antenatally can leave mothers feeling let down, gaslit and angry\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Simply being listened to and having their wishes respected appeared to have a positive influence on maternal wellbeing separate from receiving the DHM for their baby.\u003c/p\u003e\n\u003cp\u003eRelated to this was the value mothers placed on being able to follow through with their infant feeding plans. Although they experienced a complex array of emotions at not being able to breastfeed fully (or fully at first), many valued their feeding decisions being respected and the option to be able to choose to use DHM over infant formula. The relationship women have with breastfeeding extends far beyond health impacts, including bodily autonomy, and cultural and religious beliefs\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. Breastfeeding success can be closely tied to maternal identity and preferred way of mothering\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e. Our data suggest that this experience may also apply when being able to source DHM in the context of health barriers.\u003c/p\u003e\n\u003cp\u003eSome mothers reported family and friends not understanding or valuing their decision to use DHM. Some were critical, leaving mothers feeling even more unsupported at a challenging time. Family attitudes to breastfeeding can be complex, with critical or inaccurate views affecting the support new mothers receive. These are often bound up in personal difficult experiences of feeding babies, with some feeling criticised when their own daughter chooses to feed in a different way\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. Although research in this area has typically focused on breastfeeding, it is likely that similar concepts apply, alongside views around human milk as a potentially contaminated or sexual fluid\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e in contrast to carefully designed \u0026lsquo;scientific\u0026rsquo; and \u0026lsquo;sanitised\u0026rsquo; adverts of infant formula milk\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e may influence how some people react towards the concept of DHM. Further research needs to explore public perceptions and understanding of DHM and develop public health education programmes.\u003c/p\u003e\n\u003cp\u003eFinally, a number of mothers in our study noted that receiving DHM helped them to establish breastfeeding. The literature examining whether DHM supplementation has any impact on continued breastfeeding rates over formula milk supplementation is limited. One review found that DHM increased the rates of any breastfeeding at discharge from hospital but had no effect on exclusive breastfeeding rates\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e. Another study retrospectively examined the effect of DHM as a feeding supplement instead of formula milk in a level 1 NICU on exclusive breastfeeding rates at 6 months. Comparing feeding outcomes at six months for 73 infants who received formula milk supplementation before the implementation to 49 infants who received DHM after, infants who received DHM were five-fold more likely to just be receiving breastmilk at six months old\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOur data supports preliminary explanations as to why DHM may protect the breastfeeding relationship more than formula supplementation. DHM enabled their baby to be exclusively human milk fed which increased motivation to continue this \u0026ndash; more so than if formula supplementation had been introduced. This echoes findings in another study where mothers saw formula introduction as a more permanent change to their baby\u0026rsquo;s diet whereas DHM represented a short-term bridge to exclusive breastfeeding\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Additionally, some mothers commented that they felt that they needed to continue trying to establish their supply as other women had taken the time to express and donate their milk to support them.\u003c/p\u003e\n\u003cp\u003eThe study was limited in that the sample was self-selecting both in terms of participation and whether DHM was received. It is possible that parents who were already motivated to seek DHM and had a positive experience were more likely to complete the survey meaning that more negative or neutral experiences may not be included. Our decision to include fathers / partners in the research was also important as they may play a key role in DHM provision. However, only small numbers took part and care must be taken when extrapolating from these findings. Further research needs to measure prospectively any potential link between receiving DHM and anxiety and depression, considering the impact of being randomised to receive DHM or not. Our sample was also weighted towards older participants with higher levels of education; this represents a common limitation of survey research but also may reflect who is seeking out and using DHM\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. In terms of ethnicity our sample is similar to the demographic representation in the UK but likely under-sampled parents from non-White backgrounds given a higher rate or premature birth amongst Black, Asian and Minority Ethnic groups\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e. Future studies should aim to draw comparisons between experiences from different ethnic groups.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo conclude, our data clearly shows that parents who have received DHM perceived that such support improved their mental health, made them feel listened to and cared for, and that their infant feeding wishes were respected. Receiving DHM and/or not needing to give their baby formula milk were considered to be protective for mental health and wellbeing by parents who were highly motivated for their baby to receive human milk. Given the significant personal, social and financial impact that postnatal depression has upon parents and communities, our research indicates a further reason to improve the availability of DHM.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate:\u003c/em\u003e\u003c/strong\u003e Full ethical permission was gained from Swansea University College of Human and Health Sciences Research Ethics Committee. Participants gave informed consent and all aspects of the study were carried out in line with the declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials:\u003c/em\u003e\u003c/strong\u003e The datasets generated and/or analysed during the current study are not publicly available to protect participant confidentiality but are available in an anonymised form from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests:\u003c/em\u003e\u003c/strong\u003e AB is a trustee for the charity First Steps Nutrition Trust. NS is a cofounder and consultant for the Human Milk Foundation, a charity that operates the Hearts Milk Bank.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding:\u003c/em\u003e\u003c/strong\u003e None received. NS is a UKRI Future Leaders Fellow at Imperial College London (grant p76489), and UKRI funding supported the writing and publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions:\u003c/em\u003e\u003c/strong\u003e AB and NS were both responsible for study design, data analysis, draft writing and critical revisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements:\u003c/em\u003e\u003c/strong\u003e We thank the parents who took part in our study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eVictora CG, Bahl R, Barros AJ, Fran\u0026ccedil;a GV, Horton S, Krasevec J, et al. 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The failing body: Narratives of breastfeeding troubles and shame. J Ling Anthropol. 2017;27:232-51.\u003c/li\u003e\n \u003cli\u003eShepherd L, Walbey C, Lovell B. The role of social-cognitive and emotional factors on exclusive breastfeeding duration. Journal of Human Lactation. 2017;33:606-13.\u003c/li\u003e\n \u003cli\u003ePalm\u0026eacute;r L, Carlsson G, Mollberg M, Nystr\u0026ouml;m M. Severe breastfeeding difficulties: Existential lostness as a mother\u0026mdash;Women\u0026apos;s lived experiences of initiating breastfeeding under severe difficulties. International journal of qualitative studies on health and well-being. 2012;7:10846.\u003c/li\u003e\n \u003cli\u003eEsquerra-Zwiers A, Rossman B, Meier P, Engstrom J, Janes J, Patel A. \u0026ldquo;It\u0026rsquo;s Somebody Else\u0026rsquo;s Milk\u0026rdquo; Unraveling the tension in mothers of preterm infants who provide consent for pasteurized donor human milk. 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BMC pregnancy and childbirth. 2016;16:1-0.\u003c/li\u003e\n \u003cli\u003eTrickey H, Totelin LMV, Sanders J. \u0026lsquo;\u003ca href=\"http://orca.cf.ac.uk/97766\"\u003eNain, Mam and Me: Historical artefacts as prompts for reminiscence, reflection and conversation about feeding babies. A qualitative development study\u003c/a\u003e\u0026rsquo;. Research for All 2017;1:64-83\u003c/li\u003e\n \u003cli\u003eFoss KA. Marginalized Milk: \u0026ldquo;Extreme\u0026rdquo; Nursing, Milk Exchange, and Erotic Breastfeeding. In: Breastfeeding and Media 2017 (pp. 205-227). Palgrave Macmillan, Cham.\u003c/li\u003e\n \u003cli\u003eHastings G, Angus K, Eadie D, Hunt K. Selling second best: how infant formula marketing works. Globalization and Health. 2020;16:1-2.\u003c/li\u003e\n \u003cli\u003eWilliams T, Nair H, Simpson J, Embleton N. Use of donor human milk and maternal breastfeeding rates:a systematic review. J Hum Lact. 2016;32:212-20.\u003c/li\u003e\n \u003cli\u003eMerjaneh N, Williams P, Inman S, Schumacher M, Ciurte A, Smotherman C, et al. The impact on the exclusive breastfeeding rate at 6 months of life of introducing supplementary donor milk into the level 1 newborn nursery. J Perinatol. 2020;40:1109-14.\u003c/li\u003e\n \u003cli\u003eLi Y, Quigley MA, Macfarlane A, Jayaweera H, Kurinczuk JJ, Hollowell J. Ethnic differences in singleton preterm birth in England and Wales, 2006‐12: Analysis of national routinely collected data. Paediatric and perinatal epidemiology. Paediatr Perinat Epidemiol. 2019;33:449-58.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Donor human milk, Premature infant, Breastfeeding, Mental health, Infant, Mother, Qualitative research, Wellbeing","lastPublishedDoi":"10.21203/rs.3.rs-1167440/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1167440/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Donor human milk (DHM) protects the health and development of premature infants but there has been little examination of the broader impact of an infant receiving it upon parental mental health. Breastfeeding and mental health are closely tied with women who experience breastfeeding difficulties or are unable to meet their own breastfeeding goals often experiencing feelings of guilt, sadness and anger, alongside an increased risk of postnatal depression. The aim of the current study was to explore how experience of receiving DHM for their baby affected the wellbeing of parents.\u003c/p\u003e\u003cp\u003eMethods: UK parents of infants aged 0 – 12 months who had received screened DHM from a milk bank (typically on the neonatal unit or in some cases in the community) completed an online questionnaire exploring their experiences. The questionnaire included Likert scale items examining perceived impact upon infant health, own wellbeing and family functioning alongside open-ended questions exploring perceptions of how receiving DHM affected wellbeing.\u003c/p\u003e\u003cp\u003eResults: Almost all of the 107 participants (women=102) agreed that receiving DHM had a positive impact upon infant health and development, their own mental and physical health, and their family’s wellbeing. Parents felt relieved that their infant was receiving DHM for health reasons but also due to the experience of being listened to, supported and having their infant feeding decisions facilitated. Receiving DHM helped mothers to process some of their emotions at not being able to breastfeed, in part because knowing their baby was being fed gave them the space to focus on recovery and bonding with their baby.\u0026nbsp;Some parents did experience challenges, feeling guilty at receiving DHM, insecure that another woman was able to feed their baby when they could not, with some negative reactions from family. Although the impact of receiving DHM upon breastfeeding was not measured, some women who were working to build their own milk supply noted that it helped motivate them to continue.\u003c/p\u003e\u003cp\u003eConclusions: DHM may play an important role not only in protecting infant health and development but in supporting the mental health and wellbeing of mothers for whom their infant receiving human milk is important.\u0026nbsp;\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Receiving Screened Donor Human Milk for Their Infant Supports Parental Wellbeing: a Mixed-methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-12-30 19:02:48","doi":"10.21203/rs.3.rs-1167440/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-02-07T03:26:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-01-23T18:33:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2929ba43-ff04-4cad-8b5f-30c0b9845ad0","date":"2022-01-20T16:33:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"07d88bbe-aa8c-4bae-a85d-1f20551c7e7f","date":"2022-01-08T23:00:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-01-02T00:59:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-01-01T23:01:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-12-29T12:21:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-12-29T06:52:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2021-12-13T17:07:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6d04a6c-0818-4537-853f-f6a4d63d6f13","owner":[],"postedDate":"December 30th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":9445763,"name":"Maternal \u0026 Fetal Medicine"}],"tags":[],"updatedAt":"2022-05-25T10:29:19+00:00","versionOfRecord":[],"versionCreatedAt":"2021-12-30 19:02:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1167440","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1167440","identity":"rs-1167440","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}