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 , 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 .
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 , putting them at an increased risk of postnatal depression [25,26,27]. 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 , or those expressing for their premature infants in the neonatal unit have previously described . 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 .
Our data suggest 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 to a lesser degree when mothers have secured DHM for their baby. We raise the proviso of ‘sometimes to a lesser degree’ 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 . 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 . 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  or premature  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 play a practical 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 . 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 [39,40,41]. Instead, mothers felt heard, validated, and reassured, key components in protecting maternal mental health .
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 [25,26,27]. 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  in contrast to carefully designed ‘scientific’ and ‘sanitised’ adverts of infant formula milk  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.
We did not quantitatively measure mental health in this study but did reflect on duration of DHM use and how this may have affected parental wellbeing. Although the majority of participants received DHM for a week or less, our sample included 26 parents who received DHM for a longer duration. These participants were typically mothers who had longer-term health / medication issues, were undergoing cancer treatment or undergoing a mastectomy – although some received milk alongside building their own supply. Both short- and long-term recipients benefitted from receiving milk, but those receiving milk for a longer duration tended to express a stronger protective impact upon wellbeing and are overrepresented in our quotes based on the sample split. Given DHM use in the UK is predominantly restricted to shorter-term use for premature infants our initial findings her warrant further research into the potential clinical mental health impacts that might arise from greater DHM availability for those undergoing cancer treatment or living with illnesses such as HIV.
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 . 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 .
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 . 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 likely 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 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 . In terms of ethnicity our sample is similar to the demographic representation in the UK, but given a higher rate or premature birth amongst Black, Asian and Minority Ethnic groups  likely under-sampled parents from non-White backgrounds. Finally, although the sample was spread across at least nine milk banks (with some participants unsure) and participants recruited from across the UK, not every UK milk bank was represented, potentially excluding regionalised experiences.
The survey was distributed via social media. Data suggests that social media-based samples tend to be skewed towards more educated, older demographics , although further research is now needed to understand how the global Covid-19 pandemic may have affected internet use and participation in online surveys, due to major increases in internet-based activity during lockdowns . It would have been ideal to collect data via all neonatal units or milk banks in the UK to increase sample variability. However, given the timing of data collection during the pandemic and the early stages of this research topic it was felt that this would place an additional burden upon study gatekeepers who at the time of data collection were urgently focussing on ensuring DHM provision was maintained and processes were safe .
Additionally, self-selecting samples have a tendency to be weighted towards older mothers with a higher level of education for subjects such as infant feeding research even when hospital cohort studies are used. Our sample reflects similar demographics to studies that have recruited on similar research topics by inviting all eligible participants in a hospital cohort [60,61,62]. However, caution should always be taken in noting who did not take part and further research may wish to build on this basis using different methods of recruitment. More focussed recruitment techniques may be necessary to encourage and facilitate participation from parents who are typically under-represented in infant feeding studies.
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. It is likely that given our method of recruitment that fathers / partners may have been made aware of the study by their partner with both parents’ experiences added to the current data set. Although this provides added depth to the data caution in interpreting findings is needed, with further research needed to understand the experiences of fathers/ partners and how this affects DHM use and acceptability.
Finally, further research needs to measure prospectively any potential link between receiving DHM and anxiety and depression. Work is ongoing to determine whether receiving DHM reduces symptoms, or a broader impact upon perceived mental health. Looking to the longer term it would be useful to understand whether DHM impacts upon mental health only amongst parents who are strongly in favour of its use and motivated to receive it. Future randomised controlled trials will be needed to understand whether access to DHM confers a protective impact for the broader population.