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Abstract

Background:

Evidence is lacking on the phenomenon of peer-to-peer human milk-sharing in the Middle East, specifically, in Israel.

Research Aims:

This study aimed to uncover peer-to-peer human milk-sharing in Israel, learn about how and whether donors engage in safe milk handling and storage practices, and assess knowledge about human milk and breastfeeding among this milk-sharing population. We also aimed to investigate donors’ selectiveness in their decisions about to whom they donate their milk and their perceptions about the sale and purchase of human milk.

Methods:

We conducted a semi-structured online survey, including both closed- and open-ended questions and used mixed methods to analyze responses descriptively. We used non-probability sampling to obtain a broad sample of human milk donors.

Results:

Out of 250 completed surveys, most participants (87.2%, n = 218) reported engaging in safe milk-sharing practices and were generally knowledgeable about the health risks associated with milk-sharing. Participant religiosity was associated with somewhat lower hygiene practices (r = −0.15, p ≤ .05). Most of the participants (81.7%, n = 190) were against the sale of human milk. Participants generally expressed no preference about the recipient of their milk, with some exceptions.

Conclusion:

The milk-handling and storage practices of the participants in this study suggest a need to improve knowledge and awareness of safe milk storage temperature and the importance of washing hands before pumping milk, particularly within the religious sector. We propose that guidelines about safe milk-sharing practices be written and adopted by the Israeli Ministry of Health, and communicated through pediatricians, family doctors, nurses in Mother and Child Clinics (In Hebrew: Tipat Halav), and social media.

Keywords

breastfeeding donor identity food nutrition improvement health risks informal human milk sharing Israel milk sharing practices peer-to-peer human milk sharing

Background

Human milk is the optimal, most highly recommended, source of nourishment for the infant (Cassidy et al., 2019). From the dawn of humanity, mothers have been engaged in peer-to-peer human milk-sharing—feeding an infant with human milk that is not from an infant’s biological parent, and that is not shared commercially (Reyes-Foster et al., 2017). Peer-to-peer milk-sharing (also known as “informal milk-sharing”) is typically reciprocal and is usually unpaid (Peregoy et al., 2021; Thorley, 2008), unlike wet nursing, which, in some cases and throughout history, was a form of exploitation of the female body during slavery (Cassidy et al., 2019). Studies have shown that peer-to-peer human milk-sharing practices have changed since the invention of the breast pump. In addition, the expansion of social media and the internet play a major role in peer-to-peer sharing today (Peregoy et al., 2021). Recently, peer-to-peer milk-sharing has become mostly an online sharing phenomenon (Palmquist & Doehler, 2016; Peregoy et al., 2021; Thorley, 2012).

The World Health Organization (WHO) classifies human milk among a group of medical products of human origin (MPHO) (Noël & Martin, 2015; World Health Organization Task Force on Methods for the Natural Regulation of Fertility, 1998). These are “biological materials that are derived wholly or in part from the human body and are intended for clinical application” (Noël & Martin, 2015, p. 383). Whereas all other MPHO (i.e., sperm, ovarian eggs, or blood) have clear sharing regulations (e.g., donors must be selected, tested and screened), this is not the case with human milk (Noël & Martin, 2015). There are significant inconsistencies in how human milk has been defined and how its sharing has been regulated in milk banks (Klotz et al., 2022). Current applied classifications for human milk around the world include human milk as a food, as a tissue, and as a therapeutic good/medicine (Oreg & Appe, 2022). Informal sharing (e.g., online sharing) is not regulated (Cohen, 2018). This is a problem because sharing milk online involves health risks given that the milk is not monitored or pasteurized (Cassidy et al., 2019; Cohen, 2018).

Milk can include contaminants, including viruses or bacteria that enter the milk through unclean pumps, poor bottle hygiene, or improper handling and storage (Walker & Armstrong 2012). When human milk comes into contact with foreign surfaces, common bacterial flora and microbial species may be introduced via the collection apparatus. In particular, contaminated pumps can easily become reservoirs of bacterial contamination, especially after being used by multiple people and when inadequately cleaned between uses (Engür et al., 2014). Thus, the appearance of pathogenic bacteria and enterobacteria in human milk is common (Groer et al., 2020). In addition, neonatal infections have been linked to contaminated human milk (Lewin et al., 2019). There is no evidence, however, that the COVID-19 virus is infectious through breastfeeding (WHO, 2023) or through contact with surfaces (Mitchell & Weinstein, 2020).

Milk can become contaminated at any point along the milk pathway, including its expression, collection (Boo et al., 2001), transport, storage, and handling (Human Milk Banking Association of North America, 2011). In a series of case studies, Boo et al. (2001) examined the milk-expressing practices of mothers of very low birthweight babies (< 1,501 g). They found a high rate of pathogenic bacterial contamination in expressed human milk, whether it was obtained by pump, at home, or in the hospitals. Moreover, milk that is shared without monitoring can be contaminated with substances, including alcohol, nicotine, medication, and other contaminants (Arslanoglu et al., 2023; Keim et al., 2013, 2014). Indeed, in 2005, the American Academy of Pediatrics (AAP) published a statement discouraging parents from feeding preterm infants’ fresh milk from unscreened donors (Keim et al., 2013, 2014).

The U.S. Food and Drug Administration also recommends against feeding infants shared human milk that is acquired directly from individuals or via the internet (Reyes-Foster et al., 2017; U.S. Food and Drug Administration, 2018). In 2015, The European Milk Bank Association (EMBA) and Human Milk Banking Association of North America (HMBANA) issued a joint statement advising families about the possible risks of buying or sharing human milk obtained via the internet (European Milk Bank Association, 2015). In that statement they “strongly discourage internet mediated sharing or selling of breastmilk and fully endorse the promotion of breastfeeding and donation of surplus breastmilk to non-profit milk banks.” (Recommendations section) The statement further advises “all parents to be aware of the risks involved in feeding an infant with another mother’s milk and before doing so to consult a qualified healthcare professional such as a pediatrician, neonatologist or hospital infant feeding specialist” (European Milk Bank Association, 2015, Recommendations section). Alongside these recommendations, however, others have noted the possibility of engaging in milk sharing while practicing “risk reduction” (e.g., Palmquist, 2020) that can substantially reduce the contamination-related risks involved milk sharing. Moreover, it should be acknowledged that, in many cases, those who seek out human milk do not have alternatives to informal routes of milk sharing, such as those who live in locations that do not have milk banks.

Overall, the use of expressed human milk for feeding infants is growing globally, both through peer-to-peer milk-sharing and via commercial markets and derivative products (Palmquist et al., 2019). Between 2011 and 2013 an estimated 170 social media groups were dedicated to milk-sharing (Palmquist & Doehler, 2016). These included Facebook groups and groups on designated milk-sharing websites. Little is known about the extent to which milk is informally shared via the internet, and little is known about informal human milk-sharing among families and friends within their local U.S. communities (O’Sullivan et al., 2016). Palmquist and Doehler (2014) found that online milk-sharing in the United States is particularly common among middle-income, college-educated, White women. Perrin et al. (2014) estimated in their study that more than 130,000 mothers participated in that year (2014) in online milk-sharing networks around the world. In the same year, Gribble (2014) found that tens of thousands of milk-sharing exchanges are conducted worldwide through websites annually. A 2015 U.S. study estimated that there were 13,000 online posts or advertisements, annually, for milk-sharing via Facebook groups and websites (Keim, et al., 2014).

Informal peer-to-peer online human milk-sharing is rarely studied in geographical areas outside the United States. This study is the first to explore the phenomenon in Israel. Israel’s first milk bank was established in August 2020; however, it initially operated as a pilot and only in January 2021 did it begin to operate and distribute milk to all of the hospitals in the country (personal communication with the milk bank’s manager, Sharron Bransburg-Zabary, January 2023). Donating to the milk bank was therefore not an option at the time of our study. Before the new Israeli milk bank was established, the only mode of exchanging human milk was through online sharing or sharing in the community. Although there is no law against it, human milk is not generally sold in Israel. Our aim in this study was to uncover peer-to-peer human milk-sharing in Israel, learn about how and whether donors engage in safe milk handling and storage practices, and their knowledge about health-related aspects of milk sharing and breastfeeding. We also aimed to investigate donors’ selectiveness in their decision about to whom they would donate their milk and their perceptions about the sale and purchase of human milk.

Methods

Research Design

We conducted a semi-structured online survey, including both closed- and open-ended questions and used mixed methods to analyze responses descriptively. This allowed us to quantify and gain insights into the participants’ extant knowledge and attitudes about milk-sharing. We used non-probability sampling to obtain a broad sample of human milk donors. An invitation to participate in the study with a link to the online questionnaire was published on Israeli milk-sharing Facebook groups, breastfeeding mothers Facebook groups, milk-sharing WhatsApp groups, and Israel’s only milk-sharing website (Mama-Milk, a communal milk-sharing platform in Hebrew).

Our research questions were:

To what degree do Israeli human milk donors, who donate via informal routes, engage in safe milk handling and storage practices?

How knowledgeable are Israeli informal milk donors with respect to the risks involved in milk-sharing and breastfeeding?

What relationships are there between donors’ sociodemographic characteristics, their milk-related knowledge and their milk extraction, handling, and storage practices?

Are donors being selective in deciding to whom they donate their milk? If so, is there a relationship between donors’ sociodemographic characteristics and their donation preferences?

What are the donors’ beliefs about possible monetary or other compensation for their donated milk?

The study was approved by the Institutional Review Board of the participation institution (IRB approval provided on December 9th 2020, Protocol #522/20).

Key Messages

Peer-to-peer human milk sharing is rarely studied in geographical areas outside of North America, Australia, and the United Kingdom. This study is the first to explore the phenomenon in the Middle East, specifically, in Israel.

Respondents generally reported safe practices and were knowledgeable about health risks associated with milk sharing. Donor religiosity was positively associated with somewhat lower hygiene practices.

This study highlights the need for guidelines to improve knowledge and awareness of safe milk-handling and storage practices in Israel, particularly within the religious sector.

Setting and Relevant Context

At the end of 2021, Israel’s population comprised 73.9% Jews, 21.1% Arabs, and 5% Christians, Druze and others (Israel Central Bureau of Statistics, 2021). Israeli culture is very diverse and is influenced both by its Middle-Eastern heritage and Western influences. It includes the values and practices of Jews, Muslims, Christians, and others, ranging from highly religious to entirely secular. Even within the Jewish population, the diversity is substantial, with respect to variables like the degree of religiosity and ethnic background. These cultural attributes contribute to the unique nature of bodily gifting practices in Israel (Boas, 2022).

Situating human milk donation within the realm of body organ and fluid donations, Israel is among the most generous countries in the world, and the number of organ donors is constantly increasing (Boas, 2022; Global Observatory on Donation and Transplantation, 2021; National Transplant Center, 2020). In particular, Israel is a world leader in live-donor kidney donations (Kurleto et al., 2020; National Transplant Center, 2020). Between 2007 and 2018, kidney transplants from live donors increased by 339% (Kurleto et al., 2020). In 2020, 67% of all living kidney donations in Israel were from living volunteers who did not know the recipients, which is in contrast to 7% in the United States (Boas, 2022). A WHO report listed Israel's mean annual number of live kidney donors as being just over 30 people per million, which is double the ratio in the United States (Global Observatory on Donation and Transplantation, 2021). A study among Jewish Israeli live kidney donors found that the donor’s motives were “overwhelmingly altruistic.”

In addition, until 2010 a total of 561,071 Israelis had signed an Adi donor card (Adi is the name of Israel’s national transplant center), expressing their willingness to donate their organs after death, compared to 996,520 Israelis who had signed a donor card by 2020 (National Transplant Center, 2020). Similarly, there has been a constant increase in blood donations in Israel (Magen David Adom, 2022). Human milk-sharing is part of a larger phenomenon of donating bodily organs and fluids. In Israel, similar to other countries around the world (e.g., U.S., U.K., France), there are no restrictions on the sale and purchase of human milk (Oreg & Appe, 2022). Human milk is nevertheless not typically sold in Israel.

Israel’s health system tends to be supportive of breastfeeding (Zimmerman et al., 2022). By law, every Israeli resident must be registered with one of four Health Maintenance Organizations. All citizens are automatically covered by health insurance (paid through taxes; Zimmerman et al., 2022). The Ministry of Health’s guidelines direct hospital staff to provide mothers with breastfeeding assessments by breastfeeding counselors soon after giving birth (Zimmerman et al., 2022), and approximately 90% of Israeli mothers initiate breastfeeding. However, the rate of exclusive breastfeeding drops sharply in the early postnatal period (Zimmerman et al., 2022). This may be related to parents’ perceptions of insufficient support from medical staff in the later postpartum period. Medical staff have been viewed as unable to provide sufficient assistance in dealing with the challenges involved in breastfeeding (Blitman et al., 2022).

Sample

Our focus in the current study was on Israeli Jewish donors who donate milk via online and social media platforms given that, at present, the Arab population in Israel does not typically use those or any alternative milk-sharing platforms. Participation in the study was on a voluntary basis, and, as noted above, participants were recruited through non-probability sampling. The link to the survey was distributed on April 6, 2021, and the link remained active until July 9, 2021, at which point it was clear that we were not receiving additional responses to the survey. Of the 348 respondents who clicked the survey link, 250 completed the survey. The inclusion criteria were a response of “Yes” to the question: “Have you donated human milk in the last 4 years?”

Measurement

Participant demographics were measured through questions about their age, number of children, levels of education and religiosity, political view, income, profession, and the size of the town they live in. Participants’ religiosity was assessed using a Hebrew version of Chamada’s (2002) 3-item scale: “To what degree do you believe in your religious values?” “To what degree do you behave in accordance with your religious values?” and “To what extent do you practice your religion?” The scale’s internal reliability (Cronbach’s alpha) in the present study was 0.95. Participants’ political views were assessed using a question about their position ranging from left-wing to right-wing, using these five response options: left, left-center, center, center-right, right. Larger values on this variable reflect more right-wing views.

Milk handling practices were assessed with the five items used by Reyes-Foster et al. (2017) for assessing participants’ milk handling and storage practices. Items were translated to Hebrew using a translation-back-translation process and respondents chose from a five-option scale from always to never. Knowledge about health-related risks in milk sharing and breastfeeding were assessed with 16 items, composed for the present study. Eight items pertained to knowledge about the effects that milk handling procedures can have on the milk, and another eight concerned knowledge about the substances that can be transmitted through the milk. Before administering the items, we conducted a pilot study to ensure items’ readability. We sent the draft survey to 10 people, including donors, recipients, and subject-matter experts, who provided feedback on the quality and clarity of the questions, after which we revised the items to improve their clarity.

Preferences about the donation’s recipient were assessed through six questions designed for the present study. Response options for this scale were on a 5-point Likert scale, ranging from 1 “do not agree at all” to 5 “always agree.” To assess the attitude toward the sale of milk we used five items, developed for the present study. In addition, we asked the open-ended question: “Should Israeli law permit the sale and purchase of human milk? (yes/no),” followed by the questions, “if Yes, why?” and “if No, why not?”

Data Collection

The survey, in Hebrew, was distributed online between April and July 2021, at the peak of the global COVID-19 pandemic, during and between national lockdowns, using Qualtrics XM software to obtain rapid responses. Online informed consent was obtained from all participants in the opening section of the survey. Surveys were anonymous and all data were kept confidential on the researchers’ computers, protected by a password.

Data Analysis

Frequencies, means, and standard deviations were calculated for sample demographics, and then for responses to the questions pertaining to Research Questions 1 and 2 about participants’ milk handling practices and milk-related knowledge. We then calculated Spearman correlations to address Research Questions 3 and 4, pertaining to the relationships between participants’ demographics and their milk-related knowledge, practices, and preferences of donation recipients. To address Research Question 5 about participants’ attitudes toward the sale of milk, we calculated frequencies of responses to the questions about participants’ beliefs about compensation for donating human milk, and identified main themes of responses to the open-ended questions. In addition, to retest Research Question 3, we conducted logistic regressions with demographic variables (education, religiosity, income, profession, and mother’s age) as predictors of knowledge about the effects of milk-handling procedures, knowledge about the substances that can be transmitted through milk, and milk-handling and storage practices. Level of knowledge was classified as “high” for those who provided six correct answers or more (out of eight knowledge statements); 34% (n = 85) were thus classified. All others were classified as “low.” For the logistic regression predicting milk-handling and storage practices, we distinguished between “high” and “low” safe hygiene practices, by classifying those who responded “always” or “usually” to all five of the practices we asked about to the “high” group, and all others into the “low” group (57%, n = 143) were classified into the “high” safe hygiene practices category. The open-ended answers to the question about the sale of human milk were content analyzed (Hsieh & Shannon, 2005) for themes that emerged in favor of and against selling milk.

Results

Most of the participants were 26–33 years-old, with diverse religiosity and political views, and 44.3% (n = 110) had an income that was “above average” (Table 1). About 50% (n = 121) worked in a caregiving profession (e.g., social worker, nurse). Beyond the data reported in Table 1, the mean number of children was 2.1 (SD = 0.9).

Table 1.

Demographics of Study Participants (N = 250).

Category	n (%)
Mother’s age (years)
18–25	10 (4.0)
26–33	129 (51.6)
34–40	94 (37.6)
41–50	16 (6.4)
Age of donor’s infant at time of donation (months)
1< 6	43 (17.2)
≥ 6 and <12	54 (21.6)
≥12 and < 18	55 (22.0)
18+	98 (39.2)
Level of religiosity (1-5)
Low (≥ 1 and < 2)	65 (26.0)
Low-Medium (≥ 2 and < 3)	54 (21.6)
Medium-High (≥ 3 and < 4)	70 (28.0)
High (≥ 4)	61 (24.4)
Level of education
High school diploma	20 (8.0)
Bachelor’s degree	126 (50.4)
Master’s and PhD	100 (40.0)
Political view
Left	40 (16.0)
Left-center	47 (18.8)
Center	42 (16.8)
Center-right	46 (18.4)
Right	55 (22.0)
Income^a
Below average	96 (38.4)
Average	42 (16.8)
Above average	110 (44.0)
Profession (open question)^b
Therapeutic professions	121 (48.4)
Non-therapeutic professions	117 (46.8)
Size of settlement	59 (23.6)
Rural settlement or kibbutz^c
Small-medium size town ( < 200,000 residents)	99 (39.6)
Large town ( > 200,000 residents)	78 (31.2)

Note. Missing: mother’s age = 1; level of education = 4; political view = 8; income = 2; profession = 12; size of settlement = 14.

Because respondents are often sensitive about questions concerning their income, we restricted our question about income to the categories of “below average,” “average,” and “above average.”

Therapeutic professions = nurse, social worker, doctor, lactation consultant, doula, alternative medicine therapist, school counsellor, and other caretaking professional roles; non-therapeutic professions = hi-tech, engineer, accountant, architect, and similar professional roles not defined by caretaking of others.

Kibbutz refers to small Israeli settlements, traditionally based on agriculture.

Participants’ Handling and Storage Practices and Milk-Related Knowledge

Only about half (57.2%, n = 143) of the participants in our study reported “always” engaging in all five milk-handling and storage practices identified as safe (Table 2). Another 30.0% (n = 75) responded “always” about four of the five practices. The practice engaged in least frequently was that of washing hands. A much greater degree of care was reported with respect to the handling of the milk and pumping equipment (Table 2)

Table 2.

Engagement in Safe Milk-Handling and Storage Practices (N = 250).

Item	n (%)
Hands must be washed prior to expressing or pumping milk	200 (80.0)
Use containers and pumping equipment that have been washed in hot water or sanitized	240 (96.0)
Milk should not be left out at room temperature for more than 8 hours	236 (94.8)
Milk should not be frozen in household refrigerator/freezer for more than 6 months	208 (83.5)
Milk should be transported on ice	222 (89.5)
Frequency of ‘always’ responses practice questions
0 or 1	3 (1.2)
2 or 3	29 (11.6)
4	75 (30.0)
5	143 (57.2)

Note. Items taken from Reyes-Foster et al. (2017). If participants responded “always” or “often” out of a scale that also included “sometimes,” “rarely,” or “never,” their response was considered a positive response to the designated behavior.

The mean number of correct responses to the eight questions about the effects of milk-handling procedures in the portion of the survey related to milk-related knowledge was 4.9 (SD = 1.4), and the mean number of correct responses to the eight questions about milk-transmitted substances was 5.4 (SD = 1.0).

Most participants were aware that certain medication should not be taken while breastfeeding and sharing milk, and knew about the potential for contamination from unsterilized pumps. About half knew that pumped milk could contain viruses and bacteria. Only a quarter knew that human milk could be pasteurized at home. Participants were generally knowledgeable about milk-transmitted substances, with the exception that less than half knew that HIV could be transmitted through human milk. In addition, most participants were incorrect in believing that their religious dietary practices (i.e., eating kosher) influenced whether their milk was kosher (Table 3).

Table 3.

Knowledge of the Risks Involved in Milk Sharing, and General Knowledge about Human Milk and Breastfeeding (N = 250).

	Answered correctly n (%)
Knowledge about the effects of milk-handling procedures
1. Pumped human milk can contain disease-bearing viruses and bacteria (correct answer: true)	130 (52.6)
2. The hygiene of the donor mother’s hands and body affects milk quality (correct answer: true)	154 (62.4)
3. The pump used by the milk donor can transfer bacteria and viruses (correct answer: true)	228 (91.9)
4. Some medicines are forbidden when breastfeeding and donating milk (correct answer: true)	249 (99.6)
5. COVID-19 can be transmitted by surfaces such as milk pumps / milk bags / milk pump motor (correct answer: false)	148 (60.2)
6. There are techniques for pasteurizing human milk at home (correct answer: true)	60 (25.0)
7. The donation route (donation via a milk bank / online donation / direct donation from a friend or relative) does not affect milk quality (correct answer: false)	100 (40.7)
8. Human milk can be contaminated even if it is frozen and stored in the freezer (correct answer: true)	140 (57.1)
Knowledge about milk-transmitted substances
1. Alcohol is transferred through human milk (correct answer: true)	243 (97.6)
2. The donor’s nutrition affects her milk quality (correct answer: true)	163 (65.2)
3. HIV can be transmitted through human milk (correct answer: true)	117 (47.6)
4. COVID-19 can be transmitted through human milk (correct answer: false)	15 (6.0)
5. Seasonal viruses such as influenza can be transmitted through human milk (correct answer: false)	238 (95.6)
6. If the donor does not keep kosher or halal then her milk will not be kosher (correct answer: false)	214 (87.0)
7. If the donor smokes, the nicotine is transferred through her milk (correct answer: true)	216 (87.5)
8. If the donor does not smoke, but lives in a smoking environment, the nicotine is transferred through her milk (correct answer: true)	144 (58.1)

Note. This is an author-created scale.

Relationships Between Participant Demographics and Milk-Sharing Knowledge and Practices

Religiosity was the only demographic variable with a significant correlation to milk-sharing knowledge and practices (Table 4). The more religious participants were, the less informed they were about the health-related impact of how the milk and pumps were handled.

Tables 4.

Spearman Correlations Between Donor Demographics and Donors’ Milk-Sharing Knowledge and Practices (N = 217).

	Knowledge about effects of milk-handling practices	Knowledge about milk-transmitted substances	Milk-handling and storage practices
Degree of religiosity	-0.052	0.025	-0.145*
Level of education	0.013	-0.033	-0.045
Income level	-0.016	0.046	0.074
Size of settlement	0.083	0.130*	0.003

Note. The score for knowledge about the effects of milk-handling procedures was calculated by taking the average of the responses to the first eight knowledge items in Table 3. The score for knowledge about milk-transmitted substances was calculated by taking the average of the responses to the latter eight knowledge items in Table 3. The score for milk-handling and storage practices was calculated by calculating the average of the five practice items in Table 2.

p ≤ 0.05.

The only significant variable emerging from the logistic regression for predicting knowledge about the effects of milk-handling procedures was profession. The odds of respondents with therapeutic, care-giving professions to have a high level of knowledge were 2.28 times higher than for those with non-care-giving professions (Table 5).

Table 5.

Logistic Regression Using and Outcome of Knowledge About Effects of Milk-Handling Procedures as a Function of Demographic Variables (N = 220).

Independent variables	OR	95% CI		p
Independent variables	OR	LL	UL	p
Education	1.17	0.72	1.93	0.525
Religiosity	0.85	0.66	1.08	0.185
Income	0.95	0.66	1.35	0.758
Therapeutic profession	2.28	1.24	4.20	0.008
Mother’s age (in years)	0.72	0.56	1.15	0.169

Note. Level of knowledge was dichotomized so that “high” included participants (34%, n = 85) who provided six correct answers or more out of eight knowledge statements (see Table 3). All others were classified as “low.” Models: Profession defined as therapeutic (ref) versus non-therapeutic. Education, religiosity, income, and mother’s age were used in individual models as continuous variables. LL = lower limit, UL = upper limit.

With respect to knowledge about milk-transmitted substances, the only tested demographic variable that was significantly (positively) associated with this knowledge was settlement size (Table 4). In the logistic regression for predicting knowledge about milk-transmitted substances, none of the demographic variables were significant. Finally, in the logistic regression for predicting knowledge about milk-handling and storage practices, the only significant predictor was religiosity (Table 6). A higher level of religiosity was associated with a 25% lower chance of safe hygiene practices.

Table 6.

Logistic Regression of Milk-Handling and Storage Practices as a Function of Demographic Variables and Knowledge About the Effects of Milk-Handling Practices and Milk-Transmitted Substances (N = 217).

Independent variables	OR	95% CI		p
Independent variables	OR	LL	UL	p
Education	0.75	0.47	1.22	0.249
Religiosity	0.75	0.59	0.95	0.019
Income	1.29	0.91	1.83	0.146
Profession	0.91	0.50	1.63	0.739
Mother’s age (in years)	0.95	0.62	1.48	0.834
Knowledge about effects of milk-handling procedures	1.23	0.68	2.24	0.495
Knowledge about milk-transmitted substances	0.95	0.55	1.66	0.859

Note. Models: safe hygiene dichotomized so that high included participants (57%, n = 143) who responded “always” or “usually” to all five the practices, all other participants were designated as “low”; reference group for profession set as non-therapeutic professions; education, religiosity, income, and mother’s age were used in models as continuous variables the score for knowledge about the effects of milk-handling procedures was calculated by taking the average of the responses to the first eight knowledge items in Table 3; the score for knowledge about milk-transmitted substances was calculated by taking the average of the responses to the latter eight knowledge items in Table 3. LL = lower limit; UL = upper limit.

Donation Recipient Preferences

When choosing to whom to donate their milk, 94% (n = 235) of the participants reported that they had no preference with respect to the recipient’s religion or sociodemographic status; however, with respect to family structure, a quarter of them (n = 63) preferred not to donate to a family with two fathers. The correlations between level of religiosity and donation recipient preferences (Supplemental Table 1) showed that the more religious the respondent, the stronger her preference for donating her milk to a recipient from the same religion, namely, a Jewish family, and the less interested she was in donating her milk to a family with two fathers. Similarly, the more right-wing the woman’s views were, the stronger her preference for donating to Jewish recipients (Supplemental Table 2).

Participant Attitudes to the Sale of Human Milk

Most (94%, n = 234) of the participants were opposed to receiving monetary or other compensation for their donation (Supplemental Table 3). Furthermore, over 80% (n = 190) of the participants believed that the sale of human milk should be forbidden in Israel.

Respondents gave several reasons for and against permitting the sale and purchase of human milk in Israel. Six main reasons were given in favor of permitting sale, including increasing the supply for recipients and improving quality control (Table 7), and six main reasons were given against permitting sale, including ethical issues and risk of fraud (Table 8).

Table 7.

Donors’ Reasons in Favor of Permitting the Sale of Human Milk in Israel and Explanations for Their Responses (N = 38).

Reasons to permit the sale of human milk	Example of an open-ended answer	n (%)
1. Sale of human milk will encourage women to sell and increase the supply, emphasizing the fact that human milk is better than baby formula so it’s good that it will be possible to sell it. Supply and demand	Yes, because there are many babies that need human milk and often a donor cannot be found	18 (47.4)
2. It will enable control and supervision of the quality of the milk and its sharing. It will be legal like a sperm bank.	Yes, because then the market will be better controlled and parents will be able to choose whether to give their child baby formula or human milk	5 (13.2)
3. Sale of human milk is part of a woman’s right to her own body.	Why not? If a woman wants to sell and there is someone willing to pay, then it’s her private issue.	3 (7.9)
4. Pumping is hard work that deserves monetary compensation.	Being able to sell the milk will recompense the woman for the time it takes to pump (not for the milk or the bags or the transport), and this might encourage women who can donate to continue donating.	4 (10.5)
5. Human milk is baby food and its sale should be permitted, just like baby formula	To give women the option to choose, just like they have the option to choose baby formula	5 (13.2)
6. Why not?	I don’t see any reason why not.	3 (7.9)

Note. Qualitative content analysis of the answers to an open-ended question about the reasons in favor of the sale of human milk.

Table 8.

Donors’ Reasons Against Permitting the Sale of Human Milk in Israel and Explanations for Their Responses (N = 158).

Reasons to forbid the sale of human milk	Example of an open-ended answer	n (%)
1. The value of giving / altruism / organ trading is unethical / “human milk is given from the heart”	So as not to commercialize the magicLike blood, it’s something the human body produces and it doesn’t seem ethical to receive payment for it.Breastfeeding and human milk are giving, in my opinion, to your baby or someone else’s. Pure, altruistic giving. Turning human milk into a product that is bought with money hurts the aim in my opinion and hurts me.	85 (53.8)
2. The problem of controlling milk quality; an opportunity for exploitation and fraud (such as diluting milk with water); an opportunity for lawsuits	Legislation and sale of milk will make the issue very political and encourage greed and problematic trade, leading to the need for legislation and a potential black market.It’s problematic with respect to disease transmission and requires serious control. It may also lead low-income earners who require milk into a problematic situation and will of course reduce donations	25 (15.8)
3. No status equality; an opportunity for exploitation of women’s bodies; an opportunity for physiological harm to women	It’s my first instinct, that there should be no discrimination in the provision of human milk based on financial considerationsThis may cause women to withhold milk from their babies in order to sell it due to a bad financial situation. This is extreme but there are stages to the process. It reminds me of prostitution. Sorry if I’m not being clear enough.It will cause exploitation of women.	42 (26.6)
4. A mother who donates enjoys better health because of the pumping. She does not need monetary compensation. She could receive compensation for the milk bags, but no more than that.	The concern that they will dilute or add substances in order to increase the amount of milk, a concern regarding withholding of information regarding medications and state of health.	2 (1.3)
5. Sale of human milk should be forbidden to body builders; donation only to babies.	I think that milk donations should be to babies only and not to adults for bodybuilding or other reasons.	1 (0.6)
6. Consider the idea strange/indifferent	Like blood donation, the recipients usually need the milk for health purposes, so it’s not logical in my opinion that the needy should have to pay. But maybe there could be some kind of participation fee? I don’t know; it’s a strange idea.	3 (1.9)

Note. Qualitative content analysis of the answers to an open-ended question about the reasons in favor of the sale of human milk.

Discussion

Overall, the characteristics of the Israeli milk donors in our sample were similar to those of other populations around the world. Participants in this survey were mostly white, belonged to the middle class, and had tertiary education (Cohen, 2018; Gerstein Pineau, 2011; Palmquist & Doehler, 2016) The finding that over half of the participants were from caregiving professions was also similar to previous findings on the characteristics of participants to non-profit human milk banks in North America (Oreg & Appe, 2020).

Donors Milk-Handling and Storage Practices

Most participants in our study reported that they washed their hands thoroughly before handling milk, which is consistent with previous studies in the United States, where most of the research on peer-to-peer milk sharing has been conducted. For example, in a study by Reyes-Foster et al. (2017), 82.3% of the respondents reported that they always washed their hands before handling milk. In contrast, lower rates of just over 50% were found in a study of 97 milk donors in North America, Europe, Oceania, and Asia (Gribble, 2014). In our current study we expected a higher rate of hand washing, because the data were collected during the COVID-19 pandemic, and, for part of the study timeline, Israel was experiencing a peak in COVID-19. During this period, the Ministry of Health and the government broadcasted recommendations throughout the day regarding hand washing and the importance of hand and body hygiene, irrespective of milk pumping. Over all of the e-communication channels, the subject of hand washing was a central issue. Nevertheless, we found that the message was not fully implemented.

Almost all of the participants in our sample reported that their pumping equipment and storage containers were used only after they had been washed in hot water or sanitized. This finding is different from that found in studies in the United States, which revealed a much lower rate. For example, Reyes-Foster et al. (2017) found that only 78.9% of the respondents reported that they sanitized their pumping equipment. However, among our results, milk-sharing knowledge and safe milk-handling practices tended to be lower among the more religious participants. Further research, specifically with the religious community in Israel, could be conducted to uncover the barriers to safe health practices specific to this community.

We also found differences between Israeli donors and North American donors with respect to storage of the milk at room temperature. In a study of U.S. mothers, Labiner-Wolfe and Fein (2013) specified that “room temperature recommendations generally range from 3 to 8 hours, depending on the cleanliness of the conditions under which the milk was collected, and extended times are acceptable in cold rooms” (p. 2). In the present study, about 5% of Israeli participants reported that they left the pumped milk at room temperature for more than 8 hours, rather than refrigerate it, compared to 1.5% of American donors in the study by Reyes-Foster et al. (2017). Similarly, Palmquist (2020), in her U.S. study, noted that “over 95% of the respondents either never stored their milk at room temperature or did so for < 4 hours. Fewer than 1% left their pumped milk at room temperature for > 8 hours” (p. 3). In Israel, located in the Middle East, adjacent to the Mediterranean Sea, temperatures are relatively high throughout the year and very high in the summer. This latter finding is therefore disconcerting, as it endangers both milk quality and infant health.

Regarding the practice of freezing milk, here, too, there was a notable difference between Israeli donors and U.S. donors. Whereas most Israeli participants stored their milk in the family freezer for > 6 months, only 8.5% of American participants did this (Reyes-Foster et al., 2017). Similarly, Labiner-Wolfe and Fein (2013) found that “most of the respondents store their human milk within generally recommended timeframes” (p. 4). In Israel it is not possible to send milk by post or courier service; therefore, all informal milk-sharing takes place directly between donors and recipients. All sharing meetings take place face-to-face. We found that 90% of participants made sure to transfer the donated milk to the recipient while chilled on ice. This is in contrast to 54.4% of American participants in the study by Reyes-Foster et al. (2017). It is reasonable to assume that with respect to face-to-face sharing, the mutual responsibility and feeling of commitment created between the donor and the recipient carries great importance.

Donors’ Identities, and Their Attitudes Toward the Sale and Purchase of Milk

Among the main motives for human milk donation is the desire to do good, help others, save lives and foster a sense of solidarity, all of which are linked with milk donors’ identities (Oreg & Appe, 2020; Palmquist, 2020). Most Israeli participants in the present study reported that they had no preference for donating specifically to a family of similar religion, origin, or socioeconomic status. Consistent with the notions of solidarity and altruistic motives, our participants were not selective in choosing to whom to donate. Nevertheless, correlations between level of religiosity, namely, religious identity, and recipient preferences, indicated that the more religious (religious identity), and the more right-wing the participant (political identity), the stronger was her preference to donate specifically to Jewish recipients. Surprisingly, and in somewhat of a contradiction to the unifying declaration about “donating universally” to all those in need, the descriptive statistics revealed that the more religious the participant, the weaker was her willingness to donate her milk to a family with two fathers. This finding can be explained by the conservative value system of those religious donors, which highlights traditional family values. Interestingly, although 94% participants reported no preference with respect to the recipient’s religion, socioeconomic status, and ethnic background, 25% declared that they prefer not to donate to a family with two fathers. This raises interesting questions for future research about the boundaries of solidarity and giving in the Israeli context.

Professional Identity

Half of the participants identified as being in caregiving professions, which is an interesting finding compared to a previous study that explored identities of human milk donors to non-profit milk banks in North America (Oreg & Appe, 2020). Among the donors to HMBANA, the professional caregiver was identified as a dominant identity in the motive for donating milk. However, in the same study (Oreg & Appe, 2020), the reason for most donors having caregiving professional identities (including doctors, nurses, breastfeeding consultants, and social workers) was related to the fact that the milk banks were all located in hospitals. Therefore, some of the donors were exposed to the needs of hospitalized preterm babies for human milk on a daily basis. Their motive for donating was explained (in addition to altruism and solidarity with other mothers and infants) by their daily proximity and awareness of needs. Interestingly, in the present study, all participants donated via online platforms, and had no prior acquaintance with the recipients. The fact that about half of the Israeli participants were from caregiving professions can explain their self-identity as helpers and givers driving their donation even when they had never met the recipients. This self-identification can be explained by the identity theory (Charng et al., 1988), which suggests that people take on a variety of identities in the act of giving.

Religiosity as a Barrier to Human Milk-Sharing

Sharing milk carries both symbolic and tangible meanings, as can be demonstrated by the issue of religiosity and milk. A unique issue for the Israeli sample is the issue of keeping kosher, leading 87% of participants to mistakenly believe that donors’ eating habits affect the kosher status of their milk. In practice, human milk is neither “kosher" or “not kosher,” and is allowed to be consumed without any halakhic (i.e., Jewish law) restrictions, except for a restriction related to pumping milk, which is generally considered a prohibited act on Shabbat (the Jewish Sabbath). These findings can be seen not only as a misunderstanding or misinterpretation of Jewish law, but as part of the symbolism of human milk, and the attributes that are ascribed to human milk. The donor’s lifestyle, and whether they are practicing Jewish law or not, symbolically affect the “quality” of their milk and its various components.

This finding also connects to the range of identities that comprise donors’ identities and the meanings that donors and recipients give to these identities. Human milk is “colored” by the donor’s identity, and we must ask whether we can symbolically differentiate between the donor and her milk. In this sense, peer-to-peer milk-sharing enables a better personal match between donor and recipient preferences. The issue of kosher food consumption has far-reaching consequences with respect to recruiting donors to the new Israel Milk Bank; to date, approximately 1 year after its establishment, ultra-Orthodox women are not donating to the milk bank, and ultra-Orthodox babies do not feed on milk from the milk bank, due to apparent halakhic issues (Israeli milk bank manager, Sharron Bransburg-Zabary, personal communication, March 2022).

Opposition to the Sale and Purchase of Human Milk

The unique contribution of the present study is that 97.2% of Israeli participants thought that milk donors should not receive monetary compensation for their donation. Furthermore, 81% believed that the sale of human milk should be illegal. From the participants’ answers to the open-ended questions about compensating human milk donors (Supplemental Table 3), and their reasons for and against the sale of milk (Tables 7 and 8), it seems that the participants viewed milk donation as an altruistic act, attributing a symbolism to milk beyond its nutritional value. Similarly, Gribble and Hausman (2012) argue that milk-sharing is more than simply a means to feed an infant, and is a symbiotic relationship between mothers, babies, and others. Further attitudes regarding the sale of human milk reported by the study participants demonstrated the strong feelings of mutual responsibility of the donors towards the recipient families, particularly to those who cannot produce enough of their own milk, as well as concerns regarding the exploitation of women and the safety of the milk. These concerns are in line with similar findings from the literature (O’Sullivan et al., 2018).

Limitations

Most of the milk-sharing in Israel takes place within the secular community and religious Zionist Facebook groups, one main website, and WhatsApp groups. However, ultra-Orthodox Jewish donors were not represented in our sample, as they do not use the internet or smart phones. They have their own local community group (g’mach) for milk-sharing. This study took place during the first wave of the COVID-19 pandemic and the questionnaire was distributed during and in between quarantines. Therefore, we could not reach those groups within the ultra-Orthodox communities.

Another limitation relates to the methodology. A survey cannot determine whether the reporting corresponds to actual practice and is necessarily biased by selection due to the nature of recruitment. Reyes-Foster et al. (2017) pointed out that there is a social stigma attached to peer-to-peer milk-sharing. However, although we are not familiar with the extent of the social stigma in Israel, it is nevertheless possible that participants in this survey reported idealized practices. In addition, it is reasonable to assume some level of social desirability to reporting “good” practices. In addition, although the items we used in our study are closely aligned with the subject matter we wished to assess, most of them have not been validated in previous studies. Additional research would thus be valuable for assessing the validity of the new measures we used.

Conclusion

The milk-handling and storage practices of the participants who participated in this study reveal the need to improve knowledge and awareness of safe milk storage temperature and the importance of washing hands before pumping milk. We propose that guidelines about safe milk-sharing practices be written and adopted by the Israeli Ministry of Health, and communicated through pediatricians, family doctors, nurses in Mother and Child Clinics (Tipat Halav), and in the social media. These kinds of guidelines will hopefully lead to improved milk pumping and storage practices and improved health and nutrition. Furthermore, in light of the willingness of many participants to share their milk unselectively, future research should focus on uncovering the boundaries of solidarity and giving in the Israeli context, which is a largely traditional society with conservative values.

Supplemental Material

sj-docx-1-jhl-10.1177_08903344231196113 – Supplemental material for Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey

Supplemental material, sj-docx-1-jhl-10.1177_08903344231196113 for Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey by Ayelet Oreg and Maya Negev in Journal of Human Lactation

Supplemental Material

sj-docx-2-jhl-10.1177_08903344231196113 – Supplemental material for Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey

Supplemental material, sj-docx-2-jhl-10.1177_08903344231196113 for Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey by Ayelet Oreg and Maya Negev in Journal of Human Lactation

Supplemental Material

sj-docx-3-jhl-10.1177_08903344231196113 – Supplemental material for Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey

Supplemental material, sj-docx-3-jhl-10.1177_08903344231196113 for Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey by Ayelet Oreg and Maya Negev in Journal of Human Lactation

Supplemental Material

sj-docx-4-jhl-10.1177_08903344231196113 – Supplemental material for Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey

Supplemental material, sj-docx-4-jhl-10.1177_08903344231196113 for Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey by Ayelet Oreg and Maya Negev in Journal of Human Lactation

Footnotes

We thank Sharron Bransburg-Zabary for her advice and feedback on our study,and the editor and anonymous reviewers for their very helpful and constructive feedback on earlier versions of this manuscript.

Author Contributions

Ayelet Oreg: Conceptualization;Data curation;Formal analysis;Funding acquisition;Investigation;Methodology;Project administration;Writing – original draft;Writing – review & editing.

Maya Negev: Conceptualization;Data curation;Formal analysis;Investigation;Methodology;Software;Writing – review & editing.

Disclosures and Conflicts of Interest

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The authors received no financial support for the research,authorship,and/or publication of this article.

ORCID iDs

Ayelet Oreg

Maya Negev

Supplemental Material

Supplementary Material may be found in the “Supplemental material” tab in the online version of this article.

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