key: cord-0758762-n8uj52v7 authors: Cohen, Mathilde; Cassidy, Tanya title: The impact of the Covid‐19 pandemic on North American milk banks date: 2021-06-30 journal: Matern Child Nutr DOI: 10.1111/mcn.13234 sha: c23e539457f9d081974a4aa3fec040f63952caca doc_id: 758762 cord_uid: n8uj52v7 This study aims to understand the impact of the Covid‐19 pandemic on human milk banking services in North America, with a focus on the United States. We triangulated questionnaire data with interviews and text‐based website data. Of the 30 human milk bank services from which data were obtained, the majority faced substantial internal organization change in terms of staffing and protocols and experienced financial hardship in particular because of decreases in donor human milk orders. At the same time, most banks reported an increase in their numbers of donors and in the volume of milk collected. These results show that the pandemic significantly affected the way in which many North American milk banks operate, some lactating mothers donate their milk and, at least during the first few months of the crisis, certain hospitals' donor human milk ordering patterns changed. It suggests in particular that stay‐at‐home orders and the turn to remote work created the potential for a surge in human milk available for donation as a number of parents no longer needed their surplus for their own children. Legal and policy reform should focus on replicating the positive effects of the pandemic on breastfeeding by guaranteeing paid parental leave and flexible work conditions. Initiatives should also aim at counteracting its negative effects by mandating the insurance coverage of donor human milk, supporting milk banks financially and, more generally, integrating lactation and human milk banking services within the health system. HIV/AIDS, which led to the closure of many HMBs (Cassidy, 2013) , to Ebola and Zika (Gribble, Mathisen, et al., 2020) . Based on over a century's worth of experience and an excellent safety track record, they were well prepared to handle Covid-19 (Carter & Reyes-Foster, 2016; Cassidy & Dykes, 2019) . However, in the first weeks of the pandemic, two unknowns destabilized HMBs globally: Would there be a donor human milk (DHM) shortage? Could SARS-CoV-2 be transmitted through DHM? There were fears that DHM would be scarce because donors would be stressed, have diminished lactation support or be unable to travel for blood testing and dropping off their milk (Furlow, 2020) . As an HMB director interviewed for this project recounts, 'what we did not expect was that donors, instead of retreating and not donating milk, wanted to help … women came out of the woodwork and said, "what can we do to help? We'll donate our milk." ' HMBANA (2021) reported that a 'record-breaking 14,093 donors gave … in 2020, a 13% increase from 2019'. Human milk experts assumed that breastfeeding and DHM would be safe because respiratory viruses are typically not transmissible through milk and that viruses present in milk are inactivated through pasteurization. There was early evidence that SARS-CoV-2 itself was not present in milk (Chen et al., 2020) . Accordingly, HMBANA issued guidance on 6 March 2020 recommending that HMBs screen donors for Covid-19 and apply a temporary 28-day deferral to those infected or exposed, but not otherwise change their protocols. In the following months, a number of studies confirmed the safety of DHM (Chambers et al., 2020; Palmquist et al., 2020; Pitino et al., 2021; Unger et al., 2020; Walker et al., 2020) . Several research groups investigated the antibodies secreted in milk by Covid-positive people or survivors, suggesting a protective effect on infants and potential for use in drugs and therapies (Fox et al., 2020) . Building upon the growing literature on the effects of the pandemic on HMBs worldwide (Azevedo et al., 2020; Bhasin et al., 2020; Jayagobi & Mei Chien, 2020; Marinelli, 2020; Rigourd & Lapillonne, 2020; Shenker, 2021; Shenker et al., 2020; Shenker et al., 2021; Spatz et al., 2020) , this study examines its impact on North American HMBs' personnel, work organization and DHM supply and demand, with the aim to propose law and policy reforms to better support HMBs and infant feeding emergency preparedness (Gribble, 2018) . This study is based on triangulated data collection combining questionnaire responses, with interviews, and data collection from HMBs' websites, eliciting detailed understandings, conceptions, beliefs and attitudes towards the pandemic. We designed and distributed a Qualtrics-hosted online structured questionnaire in which participants replied to prompts by selecting from predetermined answers but also had opportunities to respond to open-ended questions or to add their own comments at the end of Likert scales or multiple-choice responses. Table 1 provides the exact wording of the questions used in this analysis, and a complete copy of the questionnaire can be provided upon request. The survey was approved by HMBANA, which sent it out electronically in December 2020. Currently, there are 34-member and developing HMBANA HMBs. With help from HMBANA, we classified the HMBANA HMBs as either independent or hospital based and received information that there are currently 19 independent HMBANA HMBs and 12 hospital HMBANA HMBs. Additionally, two independent and one hospital HMBANA banks are currently developing. To ensure anonymity for the developing HMBANA HMBs, we decided not to separate out the developing from established HMBANA HMBs. We also emailed the survey to six non-HMBANA HMBs (i.e., human milk services that are not members of HMBANA, some of which are not-for-profit whereas others are for-profit companies). We had responses from a total of 30 HMBs, but not all of the responses were complete. We made every effort to get completed information from all of the responding HMBs and decided to include all 30 responding HMBs for additional website data collection. Twenty-six of 34 (76.5%) HMBANA HMBs responded to the online survey, and four of six (66.7%) non-HMBANA HMBs. All but one (20 of 21 or 95%) of the independent HMBANA HMBs answered at least some of our questions, but less than half (6 of 13 or 46%) of the hospital-based HMBANA HMBs responded. Ten in-depth semistructured interviews were conducted by the first author with the personnel of nine different HMBs in Canada and the United States. The interviews took place remotely via video conferencing or over the phone between June 2020 and March 2021. Participants were recruited through a combination of snowball sampling and an invitation to participate circulated at the end of the survey questionnaire. Interview questions focused on how the pandemic affected HMBs' personnel daily work and understanding of it; milk demand, supply and handling; and relationships to co-workers and others. The interviewer followed the active interview approach (Holstein & Gulbrium, 1995) whereby participants have an active role in the process of interpretation and reflexivity rather than being • The pandemic significantly affected the way in human milk bank services operate. • During the first months of the pandemic, a number of hospitals decreased their donor human milk orders mainly due to financial and trust issues. • Stay-at-home orders and the turn to remote work created the potential for a surge in human milk available for donation as some lactating parents no longer needed their surplus milk. • Legal and policy reform should focus on guaranteeing paid parental leave, flexible work conditions, insurance coverage of donor human milk, financial support to human milk services and integration of lactation support and human milk services within the health system. passive producers of answers. Accordingly, participants were encouraged to elaborate on ideas and explain perspectives in their own words, thus creating the opportunity to gather depth of detail. Interviews were recorded and transcribed. The themes that emerged from the first five interviews were used to support content validity and generate the survey questionnaire, whereas the five last interviews were analysed to confirm findings. The protocol was approved by the UConn IRB Protocol H20-0101. All interview participants gave their informed consent, and their identities are concealed to preserve their confidentiality. Additionally, both authors conducted in-depth interviews with parents lactating during the pandemic, including human milk donors, for other projects. Though not included in the data of the present study, they informed some of its interpretations. Thirty HMB websites were visited by both authors, and the second author conducted an additional systematical review using the Wayback Machine digital archive, which enabled the collection of all references to Covid-19 (Table 1 ). The Wayback Machine is a non-profit digital library of websites that includes over 25 years of web history (Arora et al., 2016) . Websites offer unobtrusive data, and the Wayback Machine can be used to trace changes in specific websites over time, enabling researchers to analyse websites before and after specific dates (Rogers, 2017) . Researchers have long recognized the reliability of these results (Vaughan & Thelwall, 2003) . The second author looked at the websites in both March 2020 and 2021 for each of the 30 HMBs. This third component of data was used to further inform the increased confidence in our interpretations of the other data collected. Despite the fact that our sample size was 30, we choose not to conduct an inferential statistical analysis but did make use of some descriptive statistics to help to frame our data. Some of the results are presented numerically 'to facilitate pattern recognition or otherwise to extract meaning from qualitative data, account for all data, document analytic moves, and verify interpretations' (Sandelowski et al., 2009, p. 210) . The numerical data and corresponding percentages are thus not intended to create the impression that a prevalence having significance for generalization was identified. The goal is rather to highlight the connection between the various verbal data, situating research participants' responses vis-à-vis one another (Maxwell, 2010) . We used constructivist grounded ethnographic theory (Glaser, 1978; Glaser & Strauss, 1967; Schmied et al., 2015) as our primary analytic technique. This approach is rooted in the Chicago pragmatic social sciences, combining understandings of multiple realities with the mutual creation of knowledge by researchers and research participants (Altheide & Johnson, 1994; Charmaz, 1995 Charmaz, , 2000 Guba & Lincoln, 1994; Prus, 1987 Prus, , 1996 Schwandt, 1994) . We also rely on elements of Erving Goffman's (1974 Goffman's ( /1986 study of interactions to develop interpretive understanding of the data. According T A B L E 1 Type and summary of data from 30 responding human milk banks (HMBs) Please note that information about the HMBANA HMBs classification was confirmed by Pauline Sakamoto. b Please note that this indicates missing data. We had complete survey data from 27 HMBs, but we included the others because they did begin the survey. So they were included in the website analysis. to Goffman, to frame a situation (i.e., to make an interpretation and adjust to it) is a strategy used to understand and give meaning to everyday life. Frame analysis is particularly helpful when studying individuals and organizations that are familiar with and sometimes involved in scientific production, as HMB personnel tend to be aware of the formalized practice of social interaction through interviews and surveys, shaping their self-presentation and responses accordingly. All of the data collected (online questionnaire responses, interview responses and website review) were utilized to help to inform the authors regarding key themes. Initial coding began with the reading and coding into broad themes of the first five interview transcripts, which revealed that the pandemic had primarily affected HMB personnel's material and social world in very concrete ways. Thereafter, we engaged in focused coding involving in-depth analysis of the interviews together with the survey results and the websites review so as to assess similarities and differences and infer more nuanced themes. To increase the reliability of the content analysis, each author engaged in coding independently, before comparing and discussing findings with one another. The three forms of data collection have complementary strengths and weaknesses but together offer triangulated data, increasing reliability and validity in the results. The survey provided evidence of patterns among the majority of HMBs; the interviews gathered insights on HMBs' personnel attitudes, thoughts and actions; and the website provided additional text-based information. Whereas questionnaires are often seen as a more objective research tool allowing larger sample sizes, faulty design and non-responses can limit the data. All respondents were invited, so even though the survey was hosted online, concerns did not arise about the legitimacy of participants. Interviews are interpersonal, and therefore, the role of the researcher must be taken into consideration, especially when using a small sample size. The unobtrusive nature of text-based data, such as that available on websites, makes them a useful additional form of data, particularly as information changes quickly. Although our systematic analysis of HMBs' websites is limited to answering the question of whether or not Covid-19 or the pandemic were mentioned, our individual review of these websites further validated the other two sets of data and informed our interpretations. Three main themes emerged in participants' narratives, survey responses and websites. Rather than abstract concepts, concrete assemblages of people, things, ideas and processes appeared key to understanding how HMBs function and were affected by the pandemic. By focusing on the material elements of human milk banking, we gain understanding of how HMB personnel articulated and represented the crisis. 'Our typical donor is a working mother who is already pumping for her baby. We don't see people who altruistically want to pump. Ordinarily we don't, but I think during the coronavirus, we did see that.' Another HMB employee compared Covid-19 with 'other big crises, like 9/11 when people came together to give blood and to help people in a way that some of us have never seen before'. All the HMBs that answered our question about whether their protocol to screen donors changed reported modifying theirs more than once, often in a 'dynamic' fashion as they 'adapted to the pandemic' and integrated updated guidance from leading public health organiza- Regarding the results from our systematic websites data collection (Table 1) , it was most common for hospital-based HMBs to give information on the impact of Covid-19 on their protocols (five out of six HMBs), often with links to information provided by the hospital itself. The second most common result was among the non-HMBANA HMBs to not provide any Covid-19-related information at all on their websites (three out of four HMBs). As for independent HMBANA HMBs, the majority included Covid-19 on their websites (12 out of 20 HMBs), with varying levels of detail and often linking to HMBANA's own webpages. These are small numbers, and any extrapolations from these data alone would be unwise. However, coupled with our qualitative impressions from visiting websites and our other data results, these findings help to inform our theoretical discussions and conclusions. In line with 'actor-network theory' (Latour, 1987) , according to which scientific knowledge is socially constructed through processes, networks and actors through which the world is constantly being assembled, with the pandemic, DHM appeared more than ever determined by concrete inputs-operational challenges, demand/supply instability and transportation logistics, among others. The financial impact of the crisis on HMBs is likely to have been even more pronounced than the results show. North American HMBs are primarily 'small businesses' who can sometimes be in 'competition' with one another, as an HMB director emphasized, even if HMBANA members often collaborate and support one another. Some participants may have been reluctant to share information about their finances or may have softened negative information, consistent with Goffman's (1955) 'facework' theory according to which face preservation is a primary constraint on the achievement of goals in social interactions. When finances permitted, HMBs hired staffers, but finding candidates able to work flexibly proved challenging given that most were mothers. The incidence of financial hardship reflects the specificity of North American HMBs, which are predominantly small, stand-alone, private charitable organizations rather than public or inhospital services. Independent HMBs are more vulnerable to sudden changes in demand and increases in operating costs. In-hospital HMBs tend to be more financially secure and have a built-in clientele serving their own hospitalized babies. However, some suffered too as hospitals' revenues dropped, resulting in hiring freezes and forgoing overtime hours and bonuses. Beyond the concrete effects of the pandemic on operations, a recurrent theme in HMBs' personnel accounts was that the crisis exposed the lack of prioritization of lactation and infant health in North America. As one milk bank staffer observed, 'obviously the hospitals are focusing on Covid, and so since donor milk and breastfeeding are, in most people's opinions not directly related to Covid, the focus is shifting on that'. Several bank directors also lamented the initial 'fear-based' response to lactation among a number of health professionals, who questioned the safety of feeding at the breast and using DHM. The consequences of the overall decline in DHM orders for infants are yet to be determined. Further research is needed to assess whether it translated into an increase in morbidity and mortality related to prematurity and other health conditions. HMBs' ability to accept rising milk donations was also impacted as some lacked the storage capacity or funds to procure new freezers. Other HMBs were uncertain whether they could place their products. Ordinarily, they sell excess DHM to other HMBs, but as an HMB director commented, 'there was no one to send it to because everybody had that problem'. One positive effect of the surplus in DHM, however, has been to broaden the range of recipients in terms of both indications and socio-economic backgrounds. An HMB director comments, 'we gave a lot of milk to the community at reduced cost or free because we would never let it expire.' Several banks witnessed 'higher demand for scholarship milk among outpatient recipients'. Older outpatient babies with complex medical issues who are usually 'totally forgotten as far as donor milk is concerned' were now able to access it. These results matter because HMBs provide an essential service, in particular to the most vulnerable babies-hospitalized ill and premature newborns, for whom it is both an essential food and lifesaving medicine (Patel et al., 2021) . It is concerning that during the outbreak of a disease that does not circulate through human milk and has a low likelihood of making infants sick, DHM orders dropped. It is also unfortunate that some HMBs had to turn away donors considering that even in normal times too many hospitalized infants fail to receive DHM (Perrin, 2018) . Results show that infant health continues to be underprioritized by governments and public health organizations. Breastfeeding and milk sharing are relational activities involving affect and social connections (Cassidy & Dykes, 2019; Cohen, 2019) . The results also reflect the loss-or weakening-of the sense of com- First, our study is limited in its scope. Though a couple of Canadian HMBs are represented in the data set, the vast majority of participating banks are located in the United States. As a result, the analysis is US centric, as we were unable to distinguish the analysis between the two countries without exposing who contributed and who did not in Canada. Additionally, though we also collected data on lactating parents, including some who donated milk, this study centres on the perspective of HMB staff rather than the interaction between HMBs and their donors. Second, our study is limited in its findings. In the United States, there are significant disparities in the use of DHM and breastfeeding, especially along race, ethnicity and economic status (Kair et al., 2020; Patel et al., 2021; Sigurdson et al., 2019; Spatz, 2020 (Pineau, 2012) . This study supports the adoption of wide-ranging legal and policy ini- into the public health system and are themselves either public entities (or branches of public entities) or private entities benefitting from public subsidies (Pittas & Dri, 2017) . This support is urgent considering North America is expecting a sharp drop in births, which could cause further revenue loss for HMBs (Kearney & Levin, 2021 ). This public support should not just be limited to disaster and emergency situations, however. With more resources, HMBs would be able to meet the DHM needs, not only of all hospitalized infants, but also of an increased number of outpatient babies who would benefit from DHM, broadening the indications for which it is prescribed. On the demand side, the cost of providing DHM to infants, be it as inpatients at the hospital or as outpatients, should be fully covered by public and private health insurance. Currently, in most states, Medicaid does not cover DHM in the hospital, let alone at home. HMBs developed charitable programmes to deliver free or sliding scale DHM, but they cannot service all applicants. One of the silver linings of the pandemic is that it has reconfirmed that milk banking is an extremely safe and well self-regulated pursuit and that there is no need to ratchet up regulation (Picaud et al., 2021) . Finally, the pandemic exposed the need for systematic infant feeding emergency preparedness given the infant formula shortages and disruption in breastfeeding support it engendered. Access to human milk can be especially critical to the survival of infants during emergencies and disasters and a major part of both maternal and infant care (Gribble, Marinelli, et al., 2020) . Richard Banati, Medical Director of the Mothers' Milk Bank (n.d.) in Australia, refined a freeze-drying technique for DHM with the idea that it could serve to establish a human milk emergency reserve. Smith and Iellamo (2020) advocate for the adoption of a specific regulatory environment to ensure that skilled lactation support is available during emergencies as well as the option of wet nursing and peer-to-peer donor milk sharing. Emergency plans should also involve policies to keep parents and babies together, systematically teach hand expression in case of unavoidable separation so that lactation can be maintained and support the operations of HMBs. Overall, we have seen what we feel is clear evidence that HMBs deserve government support to enable and encourage breastfeeding especially during a pandemic. Some of these results may or may not be similar to those found around the world. We are currently working on a comparative research study of human milk services in several countries that will shed light on the commonalities and differences of the North American HMB pandemic experience. We received no funding for this research. We thank all the participants who agreed to complete the survey questionnaire and/or be interviewed during this particularly challenging time. For help with accessing information on HMBANA HMBs, we also thank HMBANA, Lindsay Groff, Summer Kelly and Pauline Sakamoto. For research assistance, we are grateful to Sarah Cherfan, Tanya Johnson and Olivia Pesce. The authors declare that they have no conflicts of interest. MC conceived the idea for the manuscript, reviewed the literature, conducted the survey and interview data collection, interpreted and analysed the data, drafted the article and reviewed websites. TC helped with the data collection and methods design, reviewed the literature, supported data interpretation and analysis of the data, conducted the websites data collection, prepared the table and reviewed and edited the manuscript. All authors read and approved the final submitted manuscript. The data collected for the study will not be made available to others as it would compromise research participants' confidentiality. Even deidentified data could be linked back to individuals or organizations given that the qualitative data collected present rich and detailed accounts of participants' thoughts and actions. https://orcid.org/0000-0002-8882-1211 Tanya Cassidy https://orcid.org/0000-0002-1143-378X Criteria for assessing validity in qualitative research Section on breastfeeding. Breastfeeding and the use of human milk Using the Wayback Machine to mine websites in the social sciences: A methodological resource Intervention strategies in the care routine at the human milk bank in the face of the COVID-19 pandemic The collection and preservation of breast milk. The Canadian Nurse Decreased incidence of preterm birth during coronavirus disease 2019 pandemic Role of human milk banks amid COVID 19: Perspective from a milk bank in India Is online breastfeeding a new thing? How the pandemic is changing everything and nothing Pure gold for broken bodies: Discursive techniques constructing milk banking and peer milk sharing in U Banking on milk: An ethnography of donor human milk relations HIV/AIDS and human milk banking: Controversy, complexity and culture around a global social problem Grounded theory Grounded theory: Objectivist and constructivist methods Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records Should human milk be regulated? UC Irvine Law Review Evidence of a significant secretory-IgAdominant SARS-CoV-2 immune response in human milk following recovery from COVID-19. iScience US NICUs and donor milk banks brace for COVID-19. The Lancet Child & Adolescent Health Theoretical sensitivity: Advances in the methodology of grounded theory The discovery of grounded theory: Strategies for qualitative research On face-work: An analysis of ritual elements in social interaction Frame analysis. An essay on the organization of experience A social history of wet nursing in America: From breast to bottle Supporting the most vulnerable through appropriate infant and young child feeding in emergencies Implications of the COVID-19 pandemic response for breastfeeding, maternal caregiving capacity and infant mental health Mistakes from the HIV pandemic should inform the COVID-19 response for maternal and newborn care Competing paradigms in qualitative research Research letter: Association of preterm birth rate with COVID-19 statewide stay-athome orders in Tennessee The active interview Nonprofit milk banks celebrate modest growth, despite pandemic Maintaining a viable donor milk supply during the SARS-CoV-2 (COVID-19) pandemic History of North American donor milk banking: One hundred years of progress Disparities in donor human milk supplementation among well newborns The coming COVID-19 baby bust: Update Science in action: How to follow scientists and engineers through society International perspectives concerning donor milk banking during the SARS-CoV-2 (COVID-19) pandemic Using numbers in qualitative research The COVID-19 liquid gold rush: Critical perspectives of human milk and SARS-CoV-2 infection Racial and socioeconomic disparities in breast milk feedings in US neonatal intensive care units Donor human milk and fortifier use in United States level 2, 3, and 4 neonatal care hospitals It's time to change the recommendations on COVID-19 and human milk donations Liquid gold: Breast milk banking in the United States The impact of thermal pasteurization on viral load and detectable live viruses in human milk and other matrices: A rapid review The dialog between health and foreign policy in Brazilian cooperation in human milk banks Generic social processes: Maximizing conceptual development in ethnographic research Symbolic interaction and ethnographic research: Intersubjectivity and the study of human lived experience A call to ensure access to human milk for vulnerable infants during the COVID-19 epidemic Doing web history with the internet archive: Screencast documentaries On quantitizing A mirror on practice: Using ethnography to identify and facilitate best practice in maternity and child health care Constructivist, interpretivist approaches to human inquiry Maintaining safety and service provision in human milk banking: A call to action in response to the Covid-19 pandemic. The Lancet Child & Adolescent Health Response of UK milk banks to ensure the safety and supply of donor human milk in the COVID-19 pandemic and beyond Maintaining human milk bank services throughout the COVID-19 pandemic: A global response. Maternal & Child Nutrition Racial/ethnic disparities in neonatal intensive care: A systematic review Wet nursing and donor human milk sharing in emergencies and disasters: A review Disparities in breastfeeding and use of pasteurized donor human milk Promoting and protecting human milk and breastfeeding in a COVID-19 world Banking on the body: The market in blood, milk, and sperm in modern America Holder pasteurization of donated human milk is effective in inactivating SARS-CoV-2 Scholarly use of the web: What are the key inducers of links to journal web sites SARS-CoV-2 in human milk is inactivated by Holder pasteurisation but not cold storage The impact of the Covid-19 pandemic on North American milk banks. Maternal & Child Nutrition, e13234