The triplets’ birth did not go the way their mother, Dayanis Díaz, envisioned. David, Daniel and Diego arrived via cesarean section two months early, each weighing less than four pounds.
Every year, 15 million premature babies are born around the world. Triplets like the Díaz boys have a 90 percent chance of being born early, which unfortunately means a higher chance of developing infections like sepsis or necrotizing enterocolitis (NEC), the foremost killer of premature babies. In the case of the Díaz boys, they were placed in the neonatal intensive care unit (NICU), while their mother, like many preemie moms, was struggling to produce milk.
As many as 40 percent of vulnerable babies in NICUs across the globe are not able to consume their mother’s milk – often because of maternal illness, death or other issues. Yet delaying breastfeeding, UNICEF reports, could increase the risk of neonatal mortality by 80 percent.
In most parts of the world, between the prematurity and the increased risk of infection, one or more of Díaz’s boys could have died. But Cuba, where the triplets were born, had recently imported a milk bank system from Brazil. This meant that the hospital staff fed the babies breast milk donated by women from around the country who had extra. Donated milk can be used to treat newborns, especially premature babies.
Making breast milk available to babies in need could save the lives of more than 800,000 children every year, a Lancet study recently found. The long-term economic benefits could be as high as $300 billion in health care costs for vulnerable infants. The problem is that not many countries have an effective way to get milk from the mothers who have too much to the mothers who don’t have enough – but Brazil’s system might be changing that.
Brazil is the unquestioned leader in breast milk banking. The country is home to about 230 of the world’s approximately 550 milk banks. In 2015, over 170,000 Brazilian babies received breast milk from donors. And now that Brazil has created an effective donor milk system, officials are working with other countries to establish life-saving milk banks around the world.
Milk banks operate much like a blood bank – staff screen potential donors for diseases and pasteurize the milk before distributing to patients. In Cuba, the milk banks are next to a hospital’s neonatology units, making for quick distribution.
The benefits of donated milk are so striking that the World Health Organization recommends it whenever a mother’s milk is not available.
“Human milk is not just nutrition; it’s loaded with all sorts of immune factors that can help an infant,” says Maryanne Perrin, a human milk researcher and assistant professor at University of North Carolina at Greensboro. “The more medically vulnerable an infant is, like the preterm infant, the greater the impact.”
David, Daniel and Diego Díaz were given donor milk for a month, thanks to the imported Brazilian system, allowing their mother time to establish her own supply. When they were discharged from the hospital soon thereafter, each baby weighed five and a half pounds – a weight at which they were much less likely to develop complications.
“Every day I give thanks for the patience, understanding and support of the milk bank team,” says Dayanis.
Brazil wasn’t always leading on human milk donation.
In 1975, Brazil was much like other countries when it came to breast milk. Two or three months after their babies were born, half of Brazilian mothers who had started out breastfeeding had stopped entirely. In 1986, Brazil’s breastfeeding rate was 4 percent – the lowest in all of Latin America.
Breast milk banking existed in Brazil, but its infrastructure was shoddy and its ethics questionable; donors were usually poor women exchanging breast milk for a small payout, often at the expense of their own children’s nutrition. There were only 10 donation centers in the entire country, and their equipment was limited.
Joao Aprigio Guerrade Almeida, a chemist by training, decided to change that. He and his team of researchers and government officials wanted to make a dramatic difference in Brazil’s child mortality and health outcomes.
First, they revamped the entire milk banking infrastructure. They stopped paying mothers for milk, making all donations altruistic. At the same time, they made it much easier for women to donate, creating hundreds of drop-off centers around the country and employing squads of vehicles to pick up donations. They even got firefighters involved, encouraging them to pick up donations and to turn firehouses into drop-off centers.
One important investment was new – and creatively reimagined – equipment. In the old system, Brazil used expensive imported pasteurization machines that came with quite the price tag – about $25,000 each. Almeida’s team instead began distributing machines made in Brazil for laboratory food testing, at the much lower price of $1,500 each. Almeida also repurposed sterilized mayonnaise jars and coffee cans to store the frozen milk, replacing the expensive imported beakers that accounted for an astonishing 89 percent of the banks’ operating costs.
These changes were all crucial in strengthening breast milk banking in Brazil. But perhaps most importantly, Brazil embarked on a massive marketing campaign – and an accompanying shift in national policies around breast milk.
Actresses on primetime soap operas urged mothers with extra milk to donate it; utility bills and bank statements arrived in the mail with messages about the benefits of breastfeeding. Brazil’s then-president, João Baptista de Oliveira Figueiredo, appeared in a video that aired around the country, touting the health and economic benefits of breast milk. Pediatricians encouraged mothers to donate excess milk, and doing so became easy; prescreened volunteers simply dialed a toll-free number and waited for someone to come pick up the milk.
“It is way up front there, and it is so behind the scenes here,” Perrin says of the differences between milk banking in Brazil and the United States. “They’ve done a really good job of making it part of their infrastructure.”
At the same time, Brazil placed strict limitations on how formula companies could market their products, and, crucially, legislators gave mothers four months of maternity leave – all policies that provided strong support for child and maternal health from the top down. Seeing even the president enthuse over the benefits of breast milk helped the culture around breastfeeding to shift.
In part because of this work, Brazil cut its child mortality rate by 73 percent between 1990 and 2013. It’s difficult, if not impossible, to pinpoint the extent to which milk banks contributed to Brazil’s dramatic improvements in child health, compared to programs like national immunization drives and Bolsa Familia, a social program that offers a cash stipend to low-income families in exchange for health-center visits and school attendance.
However, Almeida has said that the Brazilian network of milk banks “was one of the initiatives that most contributed to the improvement of children’s and adolescents’ health in the world,” reducing child mortality and improving child health not just in Brazil but also in countries, like Cuba, that have also implemented this system.
Kiersten Israel-Ballard, associate director of maternal, newborn and child health/nutrition at PATH, a global health nonprofit, believes milk banks played an outsize role in slashing Brazil’s child mortality rates. If you look at the charts delineating child mortality, she points out, nutrition overlays nearly all aspects of child health – from preterm birth complications to respiratory infections.
“It’s just massive,” she says.
And Brazil didn’t just stop at creating a strong system of milk banks. Officials at Fiocruz, Brazil’s health and science research center, also established a strong research focus on human milk. Much of the world’s research on breast milk now happens in Brazil.
“The number-one most powerful single intervention to save children’s lives would be breastfeeding,” says Israel-Ballard. She calls the Brazilian model of breast milk banking “astounding,” in large part because they recognized from the beginning that milk donation and breastfeeding are closely linked.
Milk banks in Brazil are known as Breastfeeding Promotion Centers, and they provide lactation support in addition to processing donated milk. Instead of just having rooms with a pasteurization machine and freezers to store milk, these banks offer spaces, decorated with posters about breastfeeding, for mothers to work with lactation consultants to feed their children. The consultants help the babies latch correctly, teach mothers different nursing positions, and show them the signs of a hungry baby.
“If you don’t have a population that’s breastfeeding, how are you going to have donors?” Israel-Ballard asks. Strengthening breastfeeding means there will be more breast milk out there in the world – including for donation.
In stark contrast to 4 percent in 1986, 36 percent of Brazilian mothers exclusively breastfeed their children until they are six months old. In comparison, 13 percent of American women exclusively breastfeed for the first six months.
Of course, not all mothers are able to breastfeed, and not everyone is interested in nursing their children. Around the world, a zeal for the benefits of breast milk has contributed to a shaming of women who choose to use infant formula – as well as for women who breastfeed in public, or eat the wrong things while breastfeeding. In 2015, the Pediatric Society of Rio Grande in Brazil launched an ad campaign telling women that “your child is what it eats,” depicting images of babies nursing at breasts transformed into burgers and doughnuts.
But helping those who want to breastfeed their infants recognize feeding cues and establish steady supplies of breast milk has ripple effects, experts say – especially when it comes to increasing milk donations.
Brazil has taken its milk-bank model around the world, establishing 28 banks internationally since 2007 – from other countries in Latin America to South Africa and Kenya. It is, in the parlance of international development, a true South-South partnership – one developing country sharing lessons with others.
However, there are organizations helping take the lessons Brazil has learned to other parts of the world. PATH, a global health organization, has worked with India, South Africa, Vietnam and Kenya to implement lessons learned in Brazil. For instance, they brought an Indian delegation to Brazil to learn best practices in strengthening India’s existing milk banks. In South Africa, PATH helped develop an inexpensive pasteurization monitoring system guided by mobile phones.
Brazil’s experiences may provide solutions for all countries seeking to improve child health outcomes, particularly regions where milk banking is on the rise but is not yet common – and that includes the United States and Europe.
The United States has only 23 milk banks – a rapid growth from just five years ago, when there were only 10. But that progress still lags far behind Brazil. Moreover, in the United States, it can be very difficult for parents who have a prescription for donor milk to pay for it, since many insurance companies will not cover donor milk outside of the hospital.
“It’s a problem. I see it as a real gap here in this country,” Perrin says. “You compare that to a place like Brazil, where milk banks are part of their medical system, and nobody pays for it.” If an infant demonstrates medical need for human milk in Brazil, then the healthcare system delivers it; it’s as simple as that.
But no system is perfect. As Kent Page points out, there are still Brazilians not being served by the current system, including some of the poorest Afro-Brazilian and indigenous communities. In other countries, there is often still not enough donated milk for the babies who need it most. In Cuba, for instance, banks only receive half the amount of milk they would like to see.
Perrin also points to the lack of international standards. “There are no standards from the World Health Organization – on safety, on recruitment, on any of that,” adds PATH’s Israel-Ballard. Breast milk is similar in many ways to blood, which is regulated by the WHO – so why not standardize practices around breast milk as well? Without global standards, she says, there are no guidelines on how to establish banks, recruit donors, process donated milk and allocate it to hospitals and patients.
In Cuba, 14-year-old Arlet Tito gave birth to twins. But one of the babies passed away, and the other – weighing just under two pounds – experienced prenatal asphyxia, or breathing problems in utero. After the traumatic birth, Arlet wasn’t comfortable nursing her tiny son, and the NICU team began feeding him donor milk.
Officials in Brazil first began talking to their Cuban counterparts about the benefits of human milk banks in 2004, and by 2005 the first pilot of a bank was launched in Cuba. The following year, 30 specialists received training on milk bank procedures from Brazilian specialists. In 2011 and 2012, six milk banks were established in Cuba’s Pinar del Río, Holguín, Granma, Santiago de Cuba, Guantánamo, and Granma provinces.
After only a few years, Cuban hospitals with milk banks have seen fewer infections and faster growth in their tiny patients, and they stay in the hospital for shorter amounts of time – an important change in a country with limited resources. In four of the six provinces, researchers note, infant mortality dropped; and breastfeeding increased in all six.
Arlet Tito received lactation counseling and education from the milk bank’s breastfeeding support team about the benefits of nursing. Soon, she changed her mind and became one of the bank’s “most prolific donors,” researchers noted, donating as many as seven liters of extra breast milk a month.
A hundred miles away, another tiny baby, Jorge Rodríguez, was born prematurely and remained in critical condition for several days. His mother also encountered complications, and she died while giving birth. The NICU team fed Jorge with donated milk from the local bank for three months, at which point he was able to go home.
His father thanked “the voluntary spirit” of the donors, like Arlet Tito, who sustained his son.
“We are very grateful,” Jorge’s father said.
This article first appeared in BRIGHT Magazine.