In the past few years, the use of donated breast milk in hospitals has skyrocketed across the country. Alabama is no exception.

The nonprofit Mothers' Milk Bank of Alabama, which opened in November 2015, accepts donated breast milk, screens it, pasteurizes it and packages it to dispense to hospitals for a processing fee that helps defray costs.

Many hospitals use it for critically ill and premature babies who aren't able to breastfeed.

Yet Medicaid and private insurance don't cover donor milk in Alabama, so hospitals have to budget for it. At a time when smaller and rural hospitals are struggling to stay open, donor milk for their babies can be an unaffordable luxury.

So as the milk pours in, proponents of donor milk are trying to answer a simple question: Who is entitled to the milk?

"Who gets donor milk should never depend on what zip code you're born into," said Naomi Bar-Yam, president of the board of the Human Milk Banking Association of North America, which oversees the MMBA and milk banks nationwide.

"That's not acceptable."

Surpassing expectations

A week after a difficult birth, Rachel Moody learned that her newborn daughter was only getting about 1 milliliter of breast milk whenever she breastfed. She should have been getting nearly 60 milliliters.

Her doctors at Brookwood Baptist Medical Center in Birmingham offered her donor milk - donated breast milk that has been screened and pasteurized - instead of formula.

Most national and international medical organizations have come out in favor of breast milk over formula for infants, citing studies showing it helps prevent digestive and respiratory diseases, and may help lessen the risk of sudden infant death syndrome and obesity. When maternal milk isn't available, the American Academy of Pediatrics and the World Health Organization have recommended that donated breast milk be given to babies.

In 2016, Alabama's newly-opened milk bank dispensed 16,000 ounces of donor milk. The bank has already surpassed that this year, dispensing more than 21,000 ounces in the first half of 2017.

The incoming milk donations have surpassed expectations, said Kristina Habchi, program director at the milk bank.

"It's relatively new for us to have a steady supply, which we're really excited about and happy to have," said Habchi. The bank has received 39,000 ounces of donated milk so far this year, and is working to process it all. That number doesn't include frozen milk currently being held by milk "depots" - donation sites throughout the state.

But even with all this milk coming in, not all Alabama babies have the option of receiving it.

The bulk of it goes to about 15 hospitals statewide, plus a couple out of state. As supply has grown, the Alabama milk bank has worked to increase its number of participating hospitals.

But they remain limited to the hospitals that can afford it. These are hospitals that are larger or wealthier, mostly in the state's urban centers.

How it works

Mothers who have an oversupply of breast milk can complete a screening process and blood test, and then donate their excess milk at one of 12 milk depots in Alabama or Georgia that will be sent to the MMBA.

The milk is logged and stored at the Mother's Milk Bank of Alabama - which is housed inside the Community Food Bank in Birmingham - until processing. Then it's combined with other milk, pasteurized, and sent off for bacterial testing at the Human Milk Banking Association of North America in Texas. Then it returns to the milk bank before being dispensed to hospitals.

A lab technician and a volunteer pool donated breast milk at the Mothers' Milk Bank of Alabama in July 2017. The milk will be pasteurized and screened before being dispensed to Alabama hospitals. (Anna Claire Vollers | avollers@AL.com)

The milk bank is a nonprofit, and sells the milk to hospitals for about $4.40 per ounce, a fee that covers screening and processing costs. There is no cost to breastmilk donors; the bank has about 100 active donors from Alabama, Georgia and Tennessee.

The milk bank has dispensed milk to 17 hospitals so far, including hospitals in Birmingham, Huntsville, Mobile, Tuscaloosa and Montgomery.

The milk bank's website indicates that the donated milk goes primarily to critically ill and premature babies. The organization requires that milk be given out at hospitals based on doctor prescription, said Habchi.

But the bank has little control over how hospitals use the milk once it's dispensed, and uses can vary widely.

For example, when moms can't produce enough milk, Huntsville Hospital offers donor milk for its very low birth weight infants in the neonatal intensive care unit. At Brookwood in Birmingham - the largest purchaser of milk from the Mother's Milk Bank of Alabama - milk is also offered to well babies outside the intensive care unit whose mothers have problems with milk production.

That's standard across the country, said Bar-Yam, who is also the executive director of the Mothers' Milk Bank Northeast in Boston.

"Once we send it to hospitals, it's their decision who gets it," said Bar-Yam. "We don't have any control over what hospitals do. We are a vendor and send the hospitals a product. And I wouldn't want to (regulate usage). Doctors know the situations of their babies better than I do."

Who gets the milk?



Hospitals have their own set of considerations, including cost and patient population, to decide who gets the milk, Bar-Yam said.

But she has seen more and more hospitals using milk on bigger babies. It all depends on priorities and available funds.

Photos of families that have donated breast milk to the Mothers' Milk Bank of Alabama line the wall outside the lab. (Anna Claire Vollers | avollers@AL.com)

In Alabama, Medicaid covers more than half of all births in the state. The flat fee that Medicaid pays a hospital for a birth covers all medicine and supplies associated with that birth, which can include formula.

"Right now there are no insurances in Alabama that cover donor human milk, so hospitals have to take it as a loss," said Habchi. "The reason Brookwood and private hospitals can afford it is because it's factored in their budget."

Other hospitals, particularly those that treat critically ill infants, could use the milk but don't have the funds for it, she said.

Rise in popularity

In 2011 there were 10 human milk banks around the country. Now there are 26. And supply is more than keeping up with demand.

The Human Milk Banking Association of North America did an internal study and found that its 26 affiliated banks have no shortage of donated milk. Last year, those banks dispensed more than 5 million ounces of milk, a 110 percent growth over the past four years.

Some of the growth is related to consumer demand, possibly the result of more published research that identifies the benefits of breast milk over formula, Bar-Yam said.

"My guess is that general concerns about pharmaceuticals is probably playing some role in this," she said. "We've gone from the 1950s (idea of) better living through chemistry to people discovering that things we've known about for millennia, like breastfeeding, do make a difference."

The Joint Commission, which accredits hospitals, now requires hospitals to track the percentage of babies that are fed breast milk only - and donor milk counts. Some hospitals may be using donor milk as a way to improve their statistics on that front.

The Surgeon General of the United States issued a call to action in 2014 that recommended hospitals promote breastfeeding. Those guidelines have led more hospitals to seek out the Baby-Friendly designation, an initiative of the World Health Organization aimed at promoting breastfeeding.

Hospitals with the Baby-Friendly designation must purchase formula at fair market price, removing the incentive to use formula as a cheaper option.

The Mothers' Milk Bank of Alabama collects, pasteurizes, screens and processes donated breast milk, which is then dispensed to hospitals and offered to babies whose mothers have trouble producing enough breast milk. (Anna Claire Vollers | avollers@AL.com)

Safety nets

The lack of availability of donor milk for sick babies in rural and smaller hospitals is a problem that needs addressing nationally, said Bar-Yam.

Alabama has 48 hospitals that offer obstetrical services, but only 15 have used donor milk through the Alabama milk bank. While Medicaid does cover donor milk in some states, it does not in Alabama, and neither do any insurance providers in the state. There are no federal regulations or Alabama laws that govern the use of donor milk.

National efforts at improving the availability of donor milk are focused on identifying safety-net hospitals - those with high percentages of Medicaid and uninsured patients - and providing education about the benefits of donor milk.

Bar-Yam said the use of donor milk could save hospitals money in the long run. Breastmilk has been shown to considerably reduce the risk of necrotizing enterocolitis, a gut infection that mainly affects premature babies and has a high mortality rate. Treatment can require expensive abdominal surgery.

"A hospital can purchase a huge amount of donor milk for one case of NEC that is prevented," she said.

Habchi said she hopes that as the milk bank continues to expand in Alabama, more resources will be available to pursue grants that could fund outreach and advocacy, and ultimately bring donor milk to more Alabama hospitals.

"Alabama has one of the lower breastfeeding rates in the nation, while having one of the highest infant mortality rates in the nation," she said. "Those two correlate."