Donor milk saves lives, but who gets it—and how—is not the same around the world. In this final part of our series, we explore how milk banking systems operate globally, what barriers exist to equitable access, and the cultural, ethical, and professional considerations that lactation consultants must navigate when supporting families across diverse communities.

Global Models of Milk Banking

Milk banking looks vastly different depending on where you are in the world. Brazil, often cited as a gold standard, has built the largest integrated network of human milk banks globally—over 200 institutions—embedded within the public health system. These banks emphasize community-based donor recruitment, broad eligibility, and free distribution of pasteurized donor human milk (PDHM), contributing to decreased infant mortality and improved breastfeeding rates (Moro & Bertaino, 2020; Shenker et al., 2023).

The United Kingdom has a well-developed but decentralized network of nonprofit milk banks, some operated by the NHS and others by independent foundations like the Human Milk Foundation. The UK model prioritizes equitable access and operates under stringent guidelines with no financial incentives for donors (Shenker et al., 2023).

In India, where neonatal mortality remains a significant challenge, milk banking is expanding rapidly. India’s government has invested in the development of Lactation Management Centers and milk banks in public hospitals to improve survival rates for low-birthweight infants. These models integrate breastfeeding support and donor milk use into neonatal care (Unger et al., 2024).

As of 2006, over 400 milk banks were operating worldwide, reflecting a growing global commitment to donor human milk despite regional differences in regulation, infrastructure, and cultural acceptance (Israel-Ballard, K., LaRose, E., & Mansen, K. 2023)

In contrast, the United States has both nonprofit milk banks (primarily under the Human Milk Banking Association of North America, or HMBANA) and a growing for-profit sector. HMBANA banks rely on voluntary donations and focus on NICU distribution, while for-profit entities operate with different goals, raising concerns about equity and exploitation (Shenker et al., 2023).

Barriers to Access: Cost, Geography, and Awareness

Even in countries with established milk banks, access to PDHM is not universal. Geographic disparities, especially in rural or low-resource settings, limit the reach of donor milk. In many places, families must travel significant distances to access milk or may not be aware that milk banking is an option at all (Moro & Bertaino, 2020).

Cost is a significant barrier, particularly in countries where donor milk is not covered by national health insurance or hospital systems. For example, in the U.S., many families face out-of-pocket costs for PDHM if their infants are not in the NICU, and Medicaid reimbursement is inconsistent across states (Shenker et al., 2023).

Cultural and Religious Considerations

Cultural and religious beliefs can also shape attitudes toward donor milk. In Muslim-majority countries, the concept of milk kinship—the belief that breastfeeding creates familial bonds that prohibit future marriage between milk-siblings—can make anonymous donation ethically and religiously problematic. Some countries, like Iran, have adopted milk banking models that avoid kinship concerns by ensuring donor identity is unknown and milk is pooled, while others like Malaysia and Turkey have explored peer-to-peer donation frameworks that allow families to discuss compatibility and kinship implications in advance (El-Khuffash & Unger, 2023).

Surveys show that Muslim parents often decline donor milk due to milk kinship concerns, even when it’s lifesaving (Ozdemir et al., 2021). Education and culturally sensitive approaches, including engaging religious scholars and providing documentation for milk kinship when needed, have shown promise in increasing acceptance (Kimani-Murage et al., 2019).

For-Profit vs. Nonprofit Milk Banking

The rise of for-profit milk companies—especially in North America—has sparked ethical debate. Unlike nonprofit milk banks that reinvest in community health and prioritize preterm infant needs, for-profit entities often collect milk from lactating people in exchange for payment and sell it to hospitals or researchers at high prices. While this may expand supply, it introduces concerns about the commodification of milk, the exploitation of vulnerable donors, and inequitable distribution (Shenker et al., 2023).

For-profit companies typically lack integrated lactation support services and have little oversight in many countries. This stands in stark contrast to nonprofit banks, which emphasize donor safety, informed consent, and maternal support. Many advocates argue that donor milk, as a human tissue, should be regulated like blood or organ donation—not treated as a commercial product (Shenker et al., 2023; Romero-Bachiller & Santoro, 2022).

Ethical Considerations and the Role of IBCLCs

Milk banking raises complex ethical questions: Who gets donor milk? Who decides? Are donors giving truly informed consent when payment is involved? How do we protect breastfeeding while also promoting donor milk use?

Lactation consultants have a role to play in ensuring ethical practices and advocating for equitable access. This includes:

• Educating families about PDHM and its appropriate use.

• Supporting culturally informed decision-making.

• Referring to milk banks that align with ethical and clinical best practices.

• Advocating for policies that expand access to nonprofit donor milk, especially for medically fragile infants and underserved communities.

As trusted providers, lactation professionals can help ensure that donor milk is used in ways that support—not undermine—breastfeeding, and that all families, regardless of background or income, have access to this lifesaving resource.

Looking Ahead

Donor milk is a global good—but not a globally equal one. From Brazil’s public network to the challenges posed by for-profit models in the U.S., the global landscape of milk banking is rich with innovation, complexity, and ongoing ethical tension. As lactation professionals, we are called not only to understand this landscape but to shape it—through advocacy, education, and a steadfast commitment to equitable infant feeding.

References

El-Khuffash, A. & Unger, S. (2012). The Concept of Milk Kinship in Islam: Issues Raised when Offering Preterm Infants of Muslin Families Donor Human Milk. Journal of Human Lactation. 29(2), 125-127. DOI: 10.1177/0890334411434803

Israel-Ballard, K., LaRose, E., & Mansen, K. (2023). The global status of human milk banking. Maternal & Child Nutrition. 20(S4):e13592. DOI: 10.1111/mcn.13592

Kimani-Murage, E. W., Wanjohi, M., Kamande, E. W., Macharia, T. N., Mwaniki, E., Zerfu, T., & Madise, N. J. (2019). Perceptions on donated human milk and human milk banking in Nairobi, Kenya. Maternal & Child Nutrition, 15(4), e12842. https://doi.org/10.1111/mcn.12842

Klotz, D., Mauch, M., Lechner, B. E., & Haiden, N. (2021). The legislative framework of donor human milk and human milk banking in Europe. Maternal & Child Nutrition, 17(1), e13079. https://doi: 10.1111/mcn.13310.

Moro, G. E., & Bertino, E. (2020). Breastfeeding, human milk collection and containers, and human milk banking: Hot topics during the COVID-19 pandemic. International Journal of Pediatrics and Adolescent Medicine, 7(3), 125–130. https://doi: 10.1177/0890334420934391.

Ozdemir, L., Bilgin, S., & Cevik, M. (2021). Turkish women’s beliefs concerning human milk banking: A qualitative study. Turkish Journal of Pediatrics, 63(5), 814–823. https://doi: 10.1177/08903344211037989.

Romero-Bachiller, C., & Santoro, E. (2022). The cryopolitics of human milk: Thermal assemblages of breast milk in donation, banking, and preservation. In M. Krueger, L. Arnaut, & A. Horstmann (Eds.), Breastfeeding and culture (pp. 157–175). Routledge. https://DOI: 10.1177/01622439221100868

Shenker, N., Twigger, A. J., Mahon, J., & Weaver, L. T. (2023). Comparison between the for-profit human milk industry and nonprofit human milk banking: Strategies to ensure equitable access to donor human milk. Maternal & Child Nutrition, 19(1), e13477. https://doi: 10.1111/mcn.13570.

Unger, S., & O’Connor, D. (2024). Review of current best practices for human milk banking. Maternal & Child Nutrition, 20(2), e13468. https://doi: 10.1111/mcn.13657