Can India bring down infant mortality with human milk banks?

MUMBAI, India — Suman Valmiki delivered a baby girl when she was just 28 weeks into her pregnancy. The infant weighed 700 grammes and was sent to the neonatal intensive care unit (NICU) at Mumbai’s LTMG Hospital, better known as Sion Hospital.

For two days, 25-year-old Valmiki was worried about her daughter going hungry – until she was told that the infant was being fed milk from a “human milk bank,” a bank which carefully stores milk donated by other lactating mothers. Later, when she was reunited with her daughter and began to feed her, it took Valmiki no convincing to donate her own milk before she was discharged from the hospital.

“I was at peace knowing that my daughter was being taken care of, even though I was not feeding her myself,” says Valmiki, cradling her newborn in her arms after feeding her some of her own milk with a spoon. Other mothers in similar situations sat next to her, also feeding their underweight and/or pre-term newborns with milk donated by other women.

In 1989, Sion Hospital launched India’s first human milk bank. Neonatologist Dr Armida Fernandez noticed that many newborns were getting diarrhoea after being fed cow’s milk immediately following their birth. The hospital is one of the country’s busiest, seeing 2,000,000 out-patients and 85,000 in-patients annually. And the gynaecology department  delivers 14,000 babies and the hospital’s milk bank supports 3,000 infants a year.

Data from India’s Ministry of Health and Family Welfare show that India has the highest mortality rate for under-five year olds in the world. Most of these deaths take place during the neonatal stage. According to the World Health Organisation (WHO), approximately 13 percent (3.5 million) of the 27 million babies born in India annually are preterm and 28 percent (7.6 million) are born with low birth weight.

Valmiki had several reasons to worry when she wasn’t allowed to see her daughter for two days after delivery: besides her extremely low birth weight, her daughter had not been receiving enough oxygen in the womb. 

The WHO stipulates that early exclusive breastfeeding has the potential to prevent 13 percent of the under-five deaths globally each year. Breast milk helps reduce necrotising enterocolitis, a serious illness which causes portions of the bowel to undergo tissue death. It also encourages the growth of healthy bacteria in newborns.

Preterm and underweight babies must be separated from their mothers while they receive special care, and the skin-to-skin contact that is necessary within the first hour of birth is absent. This is where a human milk bank steps in, providing nutrition to the infant until she or he is reunited with the mother.

When Dr Fernandez started out, she faced resistance from many mothers, who were worried about feeding their infants with the milk of another woman, especially one whose religion they don’t know. Even more recently, Dr Jayshree Mondkar, who is now head of neonatology and runs the milk bank at Sion Hospital, feels that many people are still unaware that such a concept even exists.

“Everyone is aware of blood donation, but not about milk donation,” Dr Mondkar says, adding that she often has to explain to mothers that a newborn calf is ten times the size of a newborn human infant, and so there is no way that a cow’s milk could be healthy for the infant.

Experts deem wet nursing — nursing another woman’s baby — unsafe, unless the lactating woman can be screened for possible infections. Human milk banks, meanwhile, follow careful procedures to ensure the utmost hygiene. The milk is pasteurised in a controlled environment.

Dr Komal Kuswaha, a neonatologist practising in Gorakhpur in northern India and chief co-ordinator of the Breastfeeding Promotion Network of India (BPNI), says that a baby weighing three kilogrammes needs 450 millilitres of milk a day. A healthy mother is able to produce 1600 to 1800 millilitres of milk a day, meaning there is almost always extra milk that could be pumped.

At Sion Hospital, up to four litres of milk is collected each day. Milk is also collected when mothers return to the hospital for their postpartum check-ups. In this way, the bank collects up to 1,200 litres of milk annually. Three lactation management nurses assist new mothers in lactation, while also motivating them to donate their excess milk – as happened with Valmiki.

A sample of the collected milk is sent to be cultured. The milk is immediately sent for pasteurisation, and tested again. Then it is stored in steel containers with ice packs. Every container of milk at Sion Hospital is consumed within two weeks.

Milk banks gain prominence

For advocates of human milk banks, Brazil is a leading inspiration. Human milk collection began in Brazil in the 1940s, and more than 200 centres have enabled the country to bring down its infant mortality by 73 percent since 1990. While the first human milk bank in the world dates back to 1909, in Austria, and they have existed in the United States since 1919, it is only in recent decades has there been a real blossoming of new banks around the globe.

The Indian Academy of Paediatrics set up guidelines on the functioning of the banks in 2013 which are followed by 40 milk banks across the country. Earlier this year, the Ministry of Health and Family Welfare announced a network of human milk banks for 661 newborn care units across the country and released updated guidelines on lactation management centres in public health facilities.

“Gynaecologists do not work with pediatricians, and with the necessary involvement of specialised neonatologists, the approach towards infants has been compartmentalised. It was necessary to bring all three together,” explains Ruchika Sachdeva of PATH, an international health NGO.

The guidelines also stressed that the banks should not be commercialised. The unanimous position in India’s health sector is that breastfeeding should be encouraged, and banks should be seen only as a secondary tool to support mothers in that process.

In Bengaluru, in southern India, a private company wanted to set up a commercial milk bank, but this was vehemently opposed by public health advocates on the grounds that it could exploit poorer mothers. Dr Kuswaha argues that commercialising human milk could open the door to possible adulteration with cow’s milk.

Still, there is work to be done. PATH’s baseline data in two public hospitals in Mumbai showed that 70 percent of babies born by caesarean operations were given cow’s or formula milk immediately after their births. Dr Kuswaha has also seen babies being fed water which has honey added to it.

“A baby’s intestine is permeable and immuno deficient, and so such practices hamper its health in the long run,” he says.

“We have to counsel mothers that it can take up to three days to be able to nurse their infants effectively. They doubt themselves when the baby begins to cry. Hence, breastfeeding is a technique that has to be taught,” Dr Mondkar explains.

There is the other notion that pumping out the excess milk would lead to a shortage for their own infants. “They do not realise that the more they pump out, the more they are able to produce,” he says.

At Sion Hospital, Dr Mondkar’s team ensures that infants grow by at least 1.4 kilogrammes in weight and that the mother is able to breastfeed her child before they are discharged from the hospital.

For first-time mothers like Poonam Kanaujiya, donating her excess milk was necessary even for her own health. The 21-year-old had completed her term and had delivered a son weighing 3.6 kilogrammes. But it was her heavy breasts that had made her feel weak and even feverish. As she had undergone a C-section, she donated milk twice daily, for the days she stayed at the hospital postpartum. Pumping has also helped her to develop her ability to feed her own son better.

“My mother tells me that I was undernourished as an infant, but there was no way to feed me as her breasts were not producing enough milk. I am glad that I am able to donate milk for someone else’s baby,” she says.

The milk bank offers a win-win situation to all mothers, and is no longer a radical idea in addressing issues of infant mortality. Whether public hospitals act on developing banks similar to that at Sion Hospital is yet to be seen, but the verdict is unanimous: a bank for the most nutritious and free food for an infant can go a long way towards fortifying the health of India’s newborns.