Global health policies that support the use of banked donor human milk: a human rights issue
1National Commission on Donor Milk Banking, American Breastfeeding Institute, 327 Quaker Meeting House Road, East Sandwich, MA 02537, USA
Corresponding author.Lois DW Arnold
HERE to read the entire articleReviewDonor milk banking thrives in countries such as Brazil, where there has been a concerted effort at the Health Ministry level to incorporate milk banks into health policy . Its prime mover, Dr. Joao Aprigio Guerra de Almeida, has been honored with the prestigious WHO Sasekawa prize for making an important contribution to his country's overall health by establishing a network of donor human milk banks [2,3]. In countries where donor milk banking is protected, promoted, and supported as an extension of national breastfeeding policies, milk banking is considered a reasonable and effective part of health care delivery for infants and children.Premature infants who are fed infant formula have a higher risk of developing necrotizing enterocolitis (NEC) than when they are fed human milk, either mother's own milk or banked donor milk [4-6]. In this regard, donor milk banking could be considered preventive "medicine" in the premature population; by reducing the incidence of NEC and optimizing central nervous system development, the premature infant has a better start in life than he would have if fed premature infant formula. The argument has been made  that these infants become more productive members of society as adults if their health and neurological potential are maximized through optimal nutrition and appropriate health care from the start. This argument is made despite a general lack of published research on the efficacy of banked human milk because in many parts of the world there is a general belief that human milk in any form is superior to manufactured infant formulas. This is contrary to the pervading philosophy among many health care providers, especially in the US, that infant formula and human milk are equivalent.If donor milk banking has been incorporated into national public health policy and regulation, (such as France [8,9], Germany [10,11], and the Scandinavian countries ) and/or in other countries with socialized medicine, such as Canada and Great Britain, parents do not have to pay out of pocket to receive this service for their infants; it is provided as part of a national health insurance plan to any infant with a medical need. In countries such as the United States, where there is no federal public health policy supporting donor milk banking or regulation of its operations, growth of donor milk banking services has been severely hampered and the recipient population remains underserved.This review examines the existing international policies from the United Nations, the World Health Organization and UNICEF into which donor milk banking may be specifically integrated. While these policies often do not refer directly to either donor milk banking or breastfeeding, many of them protect, promote and support optimal health. Where the support is indirect, through breastfeeding protection, promotion and support, it can be inferred that donor milk banking "fits" in these policy statements because the support is for a form of human milk delivery. These policies can therefore be interpreted as being supportive of the earliest measures to achieve optimal health, breastfeeding and its adjunct, donor milk banking. Any nation, whether signatory to these agreements or not, thus has a basis for arguing that policies already exist that protect and support donor milk banking and that these policies establish a standard for action. Even if a human rights convention is not ratified or enforced, a precedent has been set and the right remains for that country's citizens.
On December 10, 1948 the United Nations adopted the Universal Declaration of Human Rights . Article 25 states that "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care ...". Mothers and children are identified as being entitled to special care and assistance. All children should be provided with the same protection, meaning that sick or premature infants and children must be afforded the same opportunities for achieving good health as a healthy infant or child. While not specified, breastfeeding or the provision of human milk to an infant/child who is unable to nurse is of paramount importance. In the absence of their own mothers' milk, banked donor milk has a role to play in providing for health and well being of this special category of infants and children.Human rights involve the relationship between a government and its individual citizens. While individuals clearly have some responsibility in terms of their behavior, governments must also take an active role to ensure that the weakest individuals are protected equally as much as the strongest. In developing its human rights conventions, the United Nations places responsibility on governments to protect the rights of its citizens. However, UN conventions do not have the force of law in any country. It is expected that the signatory nations will develop their own legislation to implement the conventions and provide protection of basic human rights in this way [14,15].Bar-Yam [16,17] has reviewed the United Nations (UN) human rights conventions and placed breastfeeding and human milk in the conventions addressing children's rights, women's rights, and the right to health and health care. The UN conventions on children's rights clearly refer to all children and do not distinguish whether children are sick or well. What is inferred is that if a child is sick then the family and government have clear moral obligations to remedy the situation where possible to "provide the highest attainable standard of physical and mental health." [, Article 12]. Breastfeeding and human milk, including banked donor milk, take on even greater significance for premature and sick infants and children.Does "breastfeeding" mean merely consuming human milk or really being fed at the breast? If the baby/mother has the right to feed at the breast, then it is the mother's moral obligation to do so. She needs to take advantage of her right and utilize it. This requires government protection at the national level (e.g., legislation to protect families from formula company marketing tactics or legislation that protects the breastfeeding relationship for working mothers), promotion (e.g., national campaigns to inform the public of the benefits of breastfeeding/hazards of infant formula), and support (e.g., funding of mother-to-mother and peer counselor programs, doulas, and voluntary or professional breastfeeding counselors/consultants that instill self confidence in breastfeeding mothers and provide information, recommendations, and assistance when problems arise). If the mother is unable to feed at the breast, then it is the government that is morally obligated to provide another source of breastfeeding or human milk (e.g., a wet nurse or cooperating mother, where culturally acceptable, or milk from a donor milk bank). If the right is interpreted as the baby's right to be fed human milk, then the moral obligation falls on the mother to provide it. In the absence of the mother's breastfeeding or providing her own expressed milk, it falls to the government to provide human milk in some other way, such as through a milk bank .In 1967, the UN adopted the International Covenant on Economic, Social and Cultural Rights . Article 12 states that all individuals have the right to the "highest attainable standard of physical and mental health." Countries need to take steps to lower infant mortality and ensure the healthy development of the child [, p. 32]. Breastfeeding and human milk fit into this convention well. There is a definitive relationship of infant formula feeding with an increase in infant mortality rates and poorer infant and child health outcomes [19,20]. Banked donor milk has been used to reduce morbidity and infant mortality. Donor milk feedings reduce the number of days of hospitalization required by the presence of NEC. (According to Bisquera et al,  a resolved case of NEC extends the hospital stay by approximately two weeks.) Additionally, if fewer cases of NEC result, then fewer surgeries are required to remove necrotic portions of the gut and fewer individuals therefore have surgically-induced short bowel syndrome and life-long malabsorption problems .The Convention on the Elimination of All Forms of Discrimination Against Women was adopted in 1981. This convention recognizes that certain groups require special protection. According to Article 5b, "...the interest of the children is the primordial consideration in all cases." . Family education becomes an important factor so that adult family members understand the importance of motherhood and that mothers raise future members of the society and culture. Pregnant women and mothers should, therefore, be afforded special protection so that they might care for their children in an optimal way. If the interests of the child have top priority, providing them optimal nutrition when they most need it should also be a priority. Breastfeeding and banked donor milk fit here as needing special protection.Several articles in the Declaration and Convention on the Rights of the Child  also apply to donor milk banking. Article 3 reiterates that the best interests of the child are primary. This belief has previously been expressed in the earlier declarations relating to children's rights as well as other UN conventions [12,18,25]. Article 18 specifies that governments should provide assistance to families through institutional and legislative support. [, pp. 37–38]. In relation to breastfeeding and the use of human milk this means that a country has a responsibility for protecting breastfeeding through legislation, including legislation to restrict marketing practices of infant formula companies. If other forms of infant nutrition are needed, the manufacture of these foods should be regulated for safety and adequacy. In terms of donor milk banking, this means that governments need to ensure that human milk alternatives to infant formula are provided and that there exists quality control and governmental or other legislative oversight to ensure that human milk obtained from other mothers can be fed safely to an unrelated infant/child.Breastfeeding is addressed directly in the Convention on the Rights of the Child in Article 24. The article begins by saying that "States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to the facilities for the treatment of illness and rehabilitation of health." . Because donor milk is primarily used as therapeutic nutrition for infants whose health requires improvement, donor milk banks become facilities that are an integral part of the process of treatment and rehabilitation. Governments therefore need to actively become involved in the creation of these facilities and/or their operation. Various ways that governments can do this are to: make national policy statements about the importance of donor milk banking; provide seed money or continuous funding for the establishment and operation of donor milk banks; provide regulatory and research support as well as expert consultation on standards of operation; and implement the International Code of Marketing of Breast-milk Substitutes  so that donor milk can compete fairly with commercially available manufactured breast milk substitutes.Article 24 continues by stating that breastfeeding is an activity for the whole society (Section 2e). Mothers are not mandated to breastfeed, but governments are mandated to educate all mothers and parents so that they can make informed choices. [, pp 39–40] By extension, this means that parents should also be educated about the uses of banked donor milk and its benefits, so that they know about this option and can request it if necessary.