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MINI REVIEW
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 25-28

How milk banks can help bereaved mothers


1 Department of Psychiatry, NIMHANS, St. John's Medical College and Hospital, St. John's National Academy of Health Sciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, St. John's Medical College and Hospital, St. John's National Academy of Health Sciences, Bengaluru, Karnataka, India
3 Department of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

Date of Web Publication18-Feb-2019

Correspondence Address:
Dr. M Kishor
Department of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_92_18

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  Abstract 


The process of lactation continues to occur irrespective of the survival of the child, through hormonal cascades triggered over the course of physiological changes of pregnancy. This leads to a difficult predicament in bereaved mothers, where loss, grief as well as lactation have to be dealt with in addition to enduring the physical pain of childbirth. In these cases, lactation is hardly addressed during the pre- or postnatal period, leading to a significant amount of distress in the mother. Guidance regarding options of suppression, expression, and donation of breast milk along with knowledge and easy accessibility to human milk banks which specifically cater to bereaved mothers can be provided, so as to alleviate confusion and aid in informed decision-making. This paper highlights the psychological benefits of lactation in the grieving mother, which include downregulation of stress response, shortening of the grieving period, improved self-efficacy, and risk reduction for mood disorders during the postpartum period in prospective donors. It emphasizes the need for expansion of the human milk bank network to offer larger coverage and also suggests potential interventions to enhance awareness about milk banking in health-care professionals as well as the general public, ultimately leading to positive outcomes in both high-risk infants and mothers with infant loss, which are major health concerns in India and need pressing attention.

Keywords: Bereaved mothers, mental health professionals, milk banks, milk donation


How to cite this article:
Prakrithi S N, Chandran S, Kishor M. How milk banks can help bereaved mothers. Int J Health Allied Sci 2019;8:25-8

How to cite this URL:
Prakrithi S N, Chandran S, Kishor M. How milk banks can help bereaved mothers. Int J Health Allied Sci [serial online] 2019 [cited 2019 Oct 21];8:25-8. Available from: http://www.ijhas.in/text.asp?2019/8/1/25/252455




  Background Top


India has the highest number of stillbirths in the world as of 2016, with 592,000 per year.[1] This is in addition to live-born deaths, given by the infant mortality rate, which is 41/1000 live births. Besides these, there are many more pregnancy losses which would be unaccounted for or missed in statistics because of deficits in reporting due to a number of women delivering at homes and not in registered medical centers. This leads to a very large number of bereaved mothers. Furthermore, maternal, antenatal, and postnatal care is significantly inadequate, with only 51.2% of pregnant women receiving at least four antenatal visits and just 62.4% of women receiving postnatal care within 2 days of delivery.[2] On the other hand, the maternal mortality ratio is 130 maternal deaths/1000 live births,[3] leaving these infants without the benefits of maternal care and the most important source of nutrition – breast milk. The loss of either one in the mother–child dyad exerts a major impact on the other's corporeal processes and emotional states. Human breast milk has been given special importance in Indian culture through the ages, and about 60% of infants are exclusively breastfed till 6 months of age.[2] Milk banks help to provide breast milk to babies in need and also provide a meaningful use for milk from lactating mothers who have lost their children. India has around 22 milk banks as of 2016, which is a highly insufficient number to cater to the requirements and the ever-increasing demand.[4] Brazil, another developing country, however, has over 217 human milk banks, which, along with improved maternal and child health care, has helped reduce the infant mortality rate by 73%, in addition to improving psychological outcomes in bereaved mothers. This successful model is also helping in expanding the network to other countries in Latin and South America.[5] Similar strategies can be implemented to establish milk-banking initiatives in India, besides also training mental health professionals and other health-care workers to deal with maternal bereavement.

Infant death and its immediate aftermath

An infant's death leads to a sudden loss of the physiological and psychological bond between the mother and child, and the family as a whole suffers the psychosocial consequences of this traumatic experience. The psychological distress that a bereaved mother goes through can manifest as sadness, fear, anxiety, anger, intrusive thoughts, guilt, failure, loss, a sense of inadequacy, and helplessness at failing to keep the child alive.[6] Along with this, there are also other intangible losses, such as future plans and aspirations, the anticipation of the parental role, and the societal expectations. Such situations are unique and have varied emotional connotations to different mothers, depending on their personality, coping mechanisms, social background, cultural practices, and religious inclinations. In infant death, the physiological processes of the body are "unaware" of the demise and continue to progress as if the baby still existed.[7] This leads to significant confusion for the mother as the body and the mind send conflicting signals – the body continues to make milk, which the mother would find difficult to come to terms with. To further complicate matters, the question of whether to suppress or express breast milk has to be answered within a short interval after the baby's death.

Lactation after loss of the baby

Most parents would not have envisioned this eventuality, and the discomfort and silence surrounding infant death make its contemplation an even more arduous task. Health-care professionals walk on eggshells while discussing lactation with the bereaved mother and the family, resulting in bereaved mothers arriving home without knowing how to handle lactation. Sore, engorged, painful breasts can act as compounders to the psychological distress encountered by them, and expression of the breast milk is one of the alternatives to pharmacotherapy to prevent complications such as mastitis and breast abscesses.[7] Options regarding what mothers can choose to do with the milk need to be communicated in a sensitive manner. Accurate timely anticipatory guidance would equip bereaved parents to find a sense of empowerment and familiarize them with what to expect along with considerably shortening the grieving process.[7],[8]

Whether to suppress, discard or donate is an extremely personal choice of the mother. Some consider milk production as intricately connected to continuing to provide life to their infant, and infant death renders it nonfunctional and burdensome. They feel that immediate suppression is better as it will help them get over the lost pregnancy sooner, as the process of expression is a recurrent reminder of the loss and impedes the required sense of closure and moving on. Some discard the milk as they are unaware of the possibility of donation, and some may be uncomfortable with the thought of making it for another unknown child, when her own is not around anymore. Some others consider the process of continuing lactation as a time where they can grieve for the lost child and form an emotional acceptance of it. Many studies have noted that this gives a sense of purpose to bereaved mothers as they go through the process of loss and feeling of inadequacy that arises with the child's death and serves as an altruistic healing process.[9]

Psychological implications of milk donation

Using human milk donor substitutes for babies without sufficient milk has been prevalent since age-old times, described in Ayurveda as the concept of "Dhaatri" or wet nursing, where lactating women would act as donors for babies whose mothers could not produce as much milk as required due to various conditions or situations.[10] The modern answer to this is a milk bank, the responsibility of which is collecting, screening, processing, storing, distributing, and donating human milk. They help by providing an efficient way to collect and store human breast milk for a long period of time, so as to maximize the availability and help more babies. Donors go through a stringent screening process, where they are tested for communicable diseases, various drugs, and substances of abuse. The milk thus collected is pasteurized, packed in sterile bags, and stored in freezers, where they can be kept up to 6 months. The first human milk bank opened in Vienna, Austria in 1909, and the first in Asia, called Sneha, came into existence in Mumbai, in 1989 at the Sion Hospital.[4]

There is a myriad of emotional fringe benefits of milk expression and donation. It can help by improving the bereaved mother's autonomy, at least over a part of her motherhood, addressing the value attached to lactation, and has a profound impact on her identity as a mother, which would otherwise have been denied. It has been noted that bereaved mothers who choose to continue lactation for the purpose of donation report a chance to fulfill a small part of the role of motherhood that has been prematurely cut short for them. They also have the feeling of utilizing something that would otherwise have gone waste, for saving other children. The thought that they are helping another baby stay alive slightly lessens the feeling of guilt and self-directed anger associated with not being able to save their own child. Some women consider it a ritual during which they can reflect upon their loss and process their grief and regard it one of the very few positive things to come out of an extremely traumatic experience.[9] It functions as a proactive, functional, productive, and positive tool during a time of perceived powerlessness and helplessness and provides a sense of self-efficacy. By being a source of generosity and resourcefulness, it helps to make sense of the loss as a means of realizing their own self-worth, thus assisting the progression of emotional recovery. Lactation has been shown to prevent the onset of depressive symptoms by downregulating the stress response.[11] Kendall-Tackett note that it also has a potential to provide protection against postpartum mood disorders.[12] In addition, milk banks have found many innovative ways to pay tribute to deceased children and provide a positive acknowledgment to parents that their milk has saved other lives. They send personalized gifts in the baby's honor, indicating that the lost life is valued and cherished, thus making the process somewhat easier for the mother.

There are multiple issues associated with donation after bereavement. One of them is the discarding of excess milk due to unawareness about donation options and the distress associated with it. Another is promoting a positive outlook about donation, and the third wastage of precious milk is a reason in itself to promote donation to milk banks. To address this, some milk banks have started dedicated programs for bereaved mothers, but these are too few and sparse for the current demands and need considerable elaboration.[13]

Future directions – service expansion and collaboration with mental health professionals

Considering the ramifications, milk banks should be expanded to cover all areas of the country and made accessible to a majority of women in the reproductive age group. Schemes which specifically cater to bereaved mothers, which assist in emotional and psychological recovery associated with grieving, additionally providing information and resources related to milk donation are the need of the hour, and designing such programs would require active liaison with a psychiatrist. For bereaved mothers, it can be discussed during the lactation suppression conversation, by someone who is trained in bereavement counseling or by a staff member who has a good rapport with the mother. Lactation management teams formed by collaboration of a psychiatrist, clinical psychologist, and guidance counselors along with obstetricians and pediatricians would go a long way in dealing effectively with such scenarios.

It would be ideal for the obstetrician to recognize the signs of psychological de-compensation in the mother so that immediate attention is provided through timely referral to the mental health professional. A psychiatrist would be able to address adequately the emotional trauma and appraise the need for formal treatment through pharmacological or nonpharmacological methods. Since lactation management is a significant stressor, it needs to be addressed by a trained professional, who is cognizant to the emotional undercurrents associated with each decision made and how it would impact the mental well-being of the mother. There are also significant changes in the dynamics of the couple subsystem which would naturally occur with the death of their infant, along with impact on the rest of the family. Timely supportive therapy would be able to reduce the distress.

Group sessions can be conducted for bereaved parents by mental health professionals, where they can be steered through the period of grief processing in a positive direction. This would also give an opportunity to promote milk donation, by explaining the benefits of lactation and milk expression. Self-help groups organized by experienced women who could promote their own positive experiences with milk donation after infant loss can help inculcate some optimism in grieving parents. Online blog forums if created by such mothers can also play a major role in increasing the recognition of milk donation, along with the likes and shares garnered on social media for uploaded stories of these experiences.

Currently, knowledge about milk donation is poor at best, among the general public as well as the medical profession itself. Information about available options and procedures for milk donation and recruitment process along with contact details of the nearest milk banks must be made readily available to donors as well as consumers through hospitals. Explanatory posters and charts could put up in the outpatient departments and wards in the hospital so that the knowledge is disseminated to a large number of patients and caregivers and high visibility would ensure further circulation by word of mouth. This has a three-way advantage: increasing the number of women who would choose to donate, enhancing the attention provided to their psychological needs after infant death and enabling a larger number of sick children to avail benefits. These posters can be made as part of projects and activities of workshops on bereaved mothers and milk donation. These must be ideally conducted for postgraduates in obstetrics and gynecology (OBG) as well as psychiatry, nursing staff (especially neonatal intensive care unit and OBG) and clinical psychologists, and also laboratory technicians, as an immediate step, and can subsequently include undergraduate medical and nursing students at a later stage.

In recent times, there is a move to start many milk banks in India as well as other Asian countries, recommended by the international pediatric societies and organizations such as the Academy of Breastfeeding Medicine, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition, and the American Academy of Pediatrics.[14],[15],[16] There are additional problems when it comes to the national perspective. The cost of a conventional milk bank is high and unsustainable at the village or a block level in India, due to the expertise, maintenance, and financial expenses needed for pasteurization and safe storage.[17] Hospitals should actively appraise the logistics of establishing milk banks and expanding existing networks, with inputs from biomedical engineering for implementing cost-effective strategies.

Bereaved mothers would benefit considerably by the appointment of lactation management teams in each hospital, comprising the treating obstetrician, who would handle the surgical aspects, a psychiatrist, who would assess and manage the mental health of these mothers, and would assist in conveying information and providing the available choices for exercising control over their lactation in an empathetic manner. The psychologist would provide the nonpharmacological therapies, involving the mother and the couple. The psychiatric social worker would help in recognizing the geographical and sociocultural variations in perception of lactation and taboos associated with milk donation so that a comprehensive management plan is tailored for the particular mother and her unique psychosocial situation. This would lead to the optimization of a bereaved mother's lactation care and psychological support and form an ethical approach to recruit them for breast milk donation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: A systematic analysis. Lancet Glob Health 2016;4:e98-108.  Back to cited text no. 1
    
2.
Ministry of Health and Family Welfare. National Family Health Survey (NFHS-4) 2015-16. India Fact Sheet. Delhi: Government of India; 2016.  Back to cited text no. 2
    
3.
NITI Aayog. Maternal Mortality Ratio (MMR) (Per 100000 Live Births). Delhi: Government of India; 2016.  Back to cited text no. 3
    
4.
Haiden N, Ziegler EE. Human milk banking. Ann Nutr Metab 2016;69 Suppl 2:8-15.  Back to cited text no. 4
    
5.
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6.
Kay J, Roman B, Schulte H. Pregnancy loss and the grief process. In: Woods J, Woods E, editors. Loss during Pregnancy or in the Newborn Period: Principles of Care with Clinical Cases and Analyses. Pitman, NJ: Jannetti Publications; 1997. p. 5-36.  Back to cited text no. 6
    
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Cole M. Lactation after perinatal, neonatal, or infant loss. Clin Lact 2012;3:94-100.  Back to cited text no. 7
    
8.
Forrest GC, Standish E, Baum JD. Support after perinatal death: A study of support and counselling after perinatal bereavement. Br Med J (Clin Res Ed) 1982;285:1475-9.  Back to cited text no. 8
    
9.
Welborn JM. The experience of expressing and donating breast milk following a perinatal loss. J Hum Lact 2012;28:506-10.  Back to cited text no. 9
    
10.
Saini AG, Singhi P. The journey of paediatrics from Vedic to neoteric. In: Childhoods in India. India: Routledge; 2017. p. 322-46.  Back to cited text no. 10
    
11.
Groer MW, Davis MW. Cytokines, infections, stress, and dysphoric moods in breastfeeders and formula feeders. J Obstet Gynecol Neonatal Nurs 2006;35:599-607.  Back to cited text no. 11
    
12.
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.  Back to cited text no. 12
    
13.
Carroll KE, Lenne BS, McEgan K, Opie G, Amir LH, Bredemeyer S, et al. Breast milk donation after neonatal death in Australia: A report. Int Breastfeed J 2014;9:23.  Back to cited text no. 13
    
14.
The Academy of Breastfeeding Medicine: ABM clinical protocol #10: Breastfeeding the late preterm infant (340/7 to 366/7 weeks gestation) ( first revision June 2011). Breastfeed Med 2011;6:151-6.  Back to cited text no. 14
    
15.
ESPGHAN Committee on Nutrition, Arslanoglu S, Corpeleijn W, Moro G, Braegger C, Campoy C, et al. Donor human milk for preterm infants: Current evidence and research directions. J Pediatr Gastroenterol Nutr 2013;57:535-42.  Back to cited text no. 15
    
16.
Eidelman AI, Schanler RJ, Johnston M, Landers S, Noble L, Szucs K, et al. Breastfeeding and the use of human milk. Pediatrics 2012;129:e827-41.  Back to cited text no. 16
    
17.
Yadav B, Tiwari S. Human milk banking: Indian prespective. Int J Gastroenterol Hepatol Transplant Nutr 2016;3:1-4.  Back to cited text no. 17
    




 

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