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March 2015 Milk money: Should donating mothers be compensated for their milk?Kara W. Swanson Banking on the Body: The Market in Blood, Milk, and Sperm in Modern America, Cambridge, Harvard University Press, 2014 (352 pp). ISBN 9-78067428-143-1 (hard cover) RRP $64.00. Donated breast milk is a scarce resource. It is not uncommon for human milk banks to turn away requests for milk from families, based on an allocation hierarchy designed to ensure that donor breast milk is available for hospitalised preterm infants. It is also not uncommon for lactating women to feel too burdened by new motherhood and their family and career responsibilities to pursue milk donation. Would the safety and scarcity of donor milk be affected if women were paid for the milk they provided to human milk banks? This question has already been asked of blood donation systems by Richard Titmuss (1970), who compared the United Kingdom and the United States. Although blood banking is more widely known, Kara Swanson points out in her book, Banking on the Body: The Market in Blood, Milk, and Sperm in Modern America, that human milk was actually the first body product to be institutionally organised in its disembodied form (p. 17). Therefore, while I share a common question with Titmuss, the focus in this essay will be breast milk.
Swanson compares and contrasts the history of the banking of various body products, while asking critical questions about how tissues and organs are sourced and allocated today. She combines her expertise in molecular biology, biochemistry and law with her training in the history of science to explain how—with gradual technological and medical advances over the twentieth century—blood, sperm and breast milk have been successfully banked for future use in persons unknown to the donor. Although her book provides an historical framework to explore the issue of compensation for donated breast milk, breast milk is just one of three body products that Swanson explores extensively in modern American history. To understand how body banks for blood, sperm and milk came into existence, Swanson focuses on medical problems in the early-to-mid twentieth century that doctors strove to ‘cure’ through the transfer of body products from one person to another. Medical doctors are central characters in her book, and Swanson uses her scientific training to describe in fascinating detail the contributions that scientific and technological developments such as cold storage and cryopreservation have made to successful body product banking. But she also goes on to examine ethical questions raised in broader tissue economy research: Who is receiving scarce body tissues? Is their distribution fair and equitable? Are current tissue laws actually keeping tissues safe? Are suppliers of tissues being treated respectfully? (Waldby & Mitchell 2006; Waldby 2104).
Today, the safe banking and dispensing of donated breast milk to sick, premature hospitalised infants relies on several technologies. Holder pasteurisation eliminates harmful viruses and bacteria, cold chain storage ensures no bacterial growth in the milk as it is transported across vast distances, and serology screening tests milk donors for communicable diseases such as HIV and hepatitis B and C. Other crucial practices accompany these technological interventions to ensure milk safety, including the endorsement of donor milk for its therapeutic properties by medical personnel and the care labour enacted by lactating women to comply with the milk bank’s donation guidelines (Carroll 2014, 2015). THE HISTORY OF MILK BANKING IN AMERICAThe history of milk banking starts much earlier than the technological developments in the milk banking sector. Swanson traces the origins of America’s human milk banks back to 1908, when Dr Fritz Talbot, Harvard graduate and budding pædiatrician, searched the neighbourhoods of Boston to find a suitable wet nurse who could provide sufficient breast milk for a sickly infant under his care. As he crisscrossed Boston in a streetcar for three days in search for a wet nurse of ‘appropriate character’, exasperation led him to understand the need for a more reliable and accessible source of breast milk for his infant patients. By 1910, Dr Talbot had established a Directory for Wet Nurses, which offered breast milk for purchase, as well as wet nurses for hire, a system in which the recipient family paid the supplying mother for her milk. By 1927, the Directory was renamed the Directory for Mother’s Milk, as it dispensed with the wet nurse and solely distributed bottles of mother’s milk. Importantly, selling breast milk to the Directory gave destitute women a source of income. The Directory offered milk sellers the opportunity to earn money as well as additional support such as regular health inspections and food provisions. This support assisted in keeping the donating mother and her infant together. In this way, early arrangements for selling breast milk sought to serve both sick preterm infants and the donating mother. By the 1950s, however, the payment of milk donors had largely ceased, and milk banking had become a philanthropic and middle-class project and an extension of the maternal role (p. 176). Swanson argues that the normalised practice of relying upon unpaid donations to human milk banks has come about from the strong peer-to-peer ethos of milk sharing as a middle class project, a general lack of resources among milk banks to pay donors, and a broader philosophical emphasis on keeping banked milk out of the commercial sphere (p. 184). These days, American human milk banks emphasise donation as feminine empowerment and an act of a heightened maternal role, a framing that American sociologist Marissa Gernstein Pineau confirms. Gernstein Pineau describes how the donation of breast milk to human milk banks in contemporary American culture can be viewed as a display of ‘good motherhood’: not only is the mother feeding her own child with breast milk, but she has enough to share with others (Gernstein Pineau 2013). THE HISTORY OF MILK BANKING IN AUSTRALIA
Australian historian Virginia Thorley traces a similar trajectory with regards to payment for breast milk in Australia, but with some key differences to the American case (Thorley 2012). While Australian women were paid as wet nurses for their breastfeeding services until the early twentieth century, this was not followed by systematic payments for expressed milk in the form of milk stations. However, as in the United States, breast milk was sought from mothers during their early postnatal hospital stay. This milk would be pooled with other women’s milk in ‘milk kitchens’ and provided to sickly or preterm infants in the hospital whose own mothers were yet to establish their own milk supply. As the routine expression of milk fell away as a standard early postnatal practice in the hospital, breast milk was increasingly sought from community-dwelling mothers to help feed hospitalised babies. This uncompensated practice, Thorley tells, was prevalent in Australia from the 1950s until the mid-1980s, when the AIDS epidemic and awareness that the virus that causes AIDS could be transferred through breast milk saw Australia’s breast milk banks shut down. It wasn’t until 2006 that two Australian breast milk banks reopened. Today, none of the five Australian human milk banks provide monetary compensation for their donors. The latest national review of human milk banks states that ‘a prohibition on payment protects both the donor and the recipient: it can avoid inducing donors to compromise their (or their babies’) health by giving too much and it protects recipients from the risk that unhealthy donors may have been attracted by the prospect of payment’ (Commonwealth of Australia 2014, p. 6). This position connects the issues of safety, ethics and payment but does so without reference to supporting research. A CHALLENGE TO UNCOMPENSATED MILK DONATION MODELSThe primacy of the unpaid donor model is being challenged by the advent of for-profit milk banking as well as by the selling of breast milk by women online. Not-for-profit milk banks traditionally rely on voluntary, unpaid donations and have been the main way women have shared their milk with infants in need. The introduction of new models of breast milk sharing offer women a choice as to where, and to whom, their milk may flow. Some donors who choose to share their milk online report that a milk bank was not locally available or was too troublesome, while others express satisfaction from personally knowing which infant is receiving their milk (Gribble 2013). In response to such challenges, the Human Milk Banking Association of North America (HMBANA) turned to ethics and safety in their press statement on 9 December 2014 to assert its position of supporting only unpaid donations to their not-for-profit network of accredited milk banks: ‘HMBANA milk banks continue to believe that relying on volunteer donors is the only ethical way to collect and distribute the human milk donations critically ill infants desperately need’ (Human Milk Banking Association of North America 2014).
Like the national statement made about Australian milk banks, HMBANA’s press statement does not make clear how the volunteerism and the non-payment of donors ensures the ethical distribution of human milk to infants in greatest need; that is, those infants who are hospitalised and preterm. In fact, in other countries such as Denmark and Norway, human milk banks recognise the costs incurred by milk donors such as the electricity used to operate the breast pump, the time and effort it takes to pump breast milk, and the petrol and road tolls paid by women to deliver their milk to the milk bank. In this way, these countries provide both compensation to women (Grovslien & Gronn 2009; Russell 2014) and safe milk to the sickest infants in neonatal intensive care. Thus, although using different means, these Nordic models share the same goal as HMBANA and Australian banks: providing safe breast milk to those most in need. Given the discrepancy between the uncompensated donation models of American and Australian milk banks on the one hand, and compensation models offered by Norwegian and Danish milk banks on the other, Swanson’s historical overview of milk banking is timely. Swanson points out that money is changing hands all along the supply chain these days, yet payment often stops short of the women actually supplying the milk, and so women can choose to go elsewhere:
MILK MONEY?
Positions such as that outlined in HMBANA’s press release and Australia’s national review of human milk banking attempt to separate the exchange of money and breast milk donation. Yet reading Swanson’s book, it could be argued that such positions are lagging behind both ethical-legal debates and the everyday practices of some women and families. The for-profit milk banking sector in the United States, for instance, compensates some donors by assisting them with the purchase of an electric breast pump or offering to pay them by the ounce for the milk they donate. Swanson delves into these debates and firmly states her position in the first pages of her book: ‘refusing to acknowledge markets in body parts has not stopped market allocation of these medical therapeutics’ (p. 4). Swanson agrees with other American academics such as Linda Fentiman who, like Swanson, also has training in law. Fentiman argues that the horse has already bolted with regard to the commodification of breast milk (2010, 2012). For instance, advocates of breastfeeding and the use of donor milk already draw on market values when arguing, for instance, that breastfeeding reduces costs in the health system (Smith, Thompson & Ellwood 2002). Similarly, although donated breast milk may be sourced from the non-profit sector, which does not compensate its donors, there is still a cost involved in using donor milk to achieve the medically recommended exclusive human milk feeding in neonatal intensive care (Carroll & Herrmann 2013). This cost is passed on to users of donor milk, as HMBANA affiliated milk banks need to recoup their own costs associated with staff labour, milk pasteurisation and donor serological screening. The story of Michael and Annie can be used to explore how ethical questions about the role of the body, its property and the market in tissue banking are playing out in daily life in America. I encountered Michael and Annie upon my arrival in the United States. They are a young vegan couple living in the mid-west, and have chosen to structure their family around traditional gender roles. Michael is employed full-time for a computer company while Annie is a stay-at-home mum with a three-year-old and an infant. In addition to breastfeeding her infant, Annie also expressed her milk and, in her words, ‘donated’ around 200 ounces to another vegan mother who needed ‘vegan breast milk’ to give to her baby. Later in the conversation, Annie explained that, at the suggestion of her husband, she had indeed ‘sold’ her milk at a price of $2/ounce. Annie explained that she was not motivated by the prospect of earning money, but rather lending a hand to the broader cause of vegan motherhood and referred to other people online doing the same with their milk. Through breastfeeding her own infant, while providing breast milk to another mother in need, Annie engaged in precisely what sociologist Gernstein Pineu characterises as a display of ‘good motherhood’, but outside of the non-profit milk banking sector.
Researchers have registered safety concerns about the growing trend of sharing of breast milk among peers (Geraghty et al. 2013; Keim et al. 2013). However in the concluding chapter of her book, Swanson argues that a re-examination of legal frameworks and tissue transfer systems is needed. She, like others, argues against the polarisation of altruism and compensation, and suggests that both the offer of cash and a healthy degree of care and compassion on the behalf of donors can give rise to the safe provision of a bodily product from donor to recipient. Many breast milk sharing advocates concur (Akre, Gribble & Minchin 2011). Most importantly, Swanson makes it clear that it is time to work out how this sort of model can be legally supported, so that already scarce body products can be made more available to those in need and more equitably and safely:
Perhaps this is one lesson we can learn from Swanson’s extensive work. Research needs to examine the effect of compensation on the rate of milk donations and the associated level of safety. Looking to the contemporary milk banking sector in Denmark, Austria and Norway could be one strategy. But Swanson’s book suggests that reflecting on breast milk sharing in twentieth American century may also be a good place to start. REFERENCESAkre, J., Gribble, K. & Minchin, M. 2011, ‘Milk sharing: From private practice to public pursuit’, International Breastfeeding Journal, vol. 6, no. 8, pp. 1–3. Carroll, K. 2014, ‘Body dirt or liquid gold? How the “safety” of donated breast milk is constructed for use in neonatal intensive care’, Social Studies of Science, vol. 44, no. 3, pp. 466–485. Carroll, K. 2015, ‘Breast milk donation as care work’, in Ethnographies of Breastfeeding: Cultural Contexts and Confrontations, eds T. Cassidy & A. El-Tom, Bloomsbury, London. Carroll, K. & Herrmann, K. 2013, ‘The cost of using donor human milk in the NICU to achieve exclusively human milk feeding through 32 weeks postmenstrual age’, Breastfeeding Medicine, vol. 8, no. 3, pp. 286–290. Commonwealth of Australia 2014, Donor Human Milk Banking in Australia: Issues and Background Paper, Department of Health, Commonwealth of Australia, Canberra. Fentiman, L. 2010, ‘Marketing mother’s milk: The commodification of breastfeeding and the new markets for breast milk and infant formula’, Nevada Law School Journal, vol. 10, no. 1, pp. 29–81. Fentiman, L. 2012, ‘Marketing mother’s milk: The markets for human milk and infant formula’, in Beyond Health, Beyond Choice, eds P. Smith, B. Hausman & M. Labbok, Rutgers University Press, New Brunswick. Geraghty, S., McNamara, K., Dillon, C., Hogan, J., Kwiek, J. & Keim, S. 2013, ‘Buying human milk via the Internet: Just a click away’, Breastfeeding Medicine, vol. 8, no. 6, pp. 474–478. Gernstein Pineau, M. 2013, ‘Giving milk, buying milk: The influence of mothering, ideologies and social class in donor milk banking’, in Breastfeeding: Global Practices, Challenges, Maternal Health and Infant Outcomes, ed. T. Cassidy, Nova Publishers, New York. Gribble, K. 2013, ‘Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks’, Journal of Obstetric, Gynecologic, & Neonatal Nursing, vol. 42, no. 4, pp. 451–461. Grovslien, A. & Gronn, M. 2009, ‘Donor milk banking and breastfeeding in Norway’, Journal of Human Lactation, vol. 25, no. 2, pp. 206–210. Human Milk Banking Association of North America 2014, ‘Human Milk Banking Association of North America takes a stand against paying for donations’, HMBANA Matters, Fort Worth, Texas. Keim, S., Hogan, J., McNamara, K., Gudimetla, V., Dillon, C., Kwiek J. & Geraghty S. 2013, ‘Microbial contamination of human milk purchased via the internet’, Pediatrics, vol. 132, no. 5, pp. e1227-e1235. Russell, H. 2014, ‘Iceland to import breast milk from Denmark’, The Guardian, 22 October [Online], Available: http://www.theguardian.com/world/2014/oct/22/iceland-to-import-breast-milk-denmark [2015, Mar 19]. Smith, J., Thompson, J. & Ellwood, D. 2002, ‘Hospital system costs of artificial infant feeding: Estimates for the Australian Capital Territory’, Australian and New Zealand Journal of Public Health, vol. 26, no. 6, pp. 543–51. Thorley, V. 2012, ‘Human milk banking to 1985’, Breastfeeding Review, vol. 20, no. 1, pp. 17–23. Waldby, C. 2014, ‘“Banking time”: Egg freezing and the negotiation of future fertility’, Culture, Health, & Sexuality, vol. 17, no. 4, pp. 470–482. Waldby, C. & Mitchell, R. 2006, Tissue Economies: Blood, Organs, and Cell Lines in Late Capitalism, Duke University Press, Durham and London. Katherine Carroll is an Assistant Professor in the Faculty of Health Sciences at Mayo Clinic in the United States. Her ethnographic research has examined human milk donation, human milk banking, donor human milk use in neonatal intensive care units and human milk banks in the United States and Australia. Her research interests extend to other aspects of perinatal medicine, including egg freezing and egg donation for fertility preservation. |
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