If you had told me a year ago that I would be sat here, now, writing to midwives about breast milk, I would have been incredulous. As an economist, working in and around government for more than half a decade, I have written about everything from voter registration to antimicrobial resistance, tax compliance, and giving investment bankers sweets. Having graduated in the middle of the financial crisis, however, I've always tried to stick to my brief: talk about the numbers. If 2008 taught us nothing else, it should have been that economists are at their worst when they're trying (ill-advisedly) to teach their grandmothers to suck eggs. I hope I have steered clear of this so far, yet here I am, writing to midwives about breast milk. How did this happen?
My son, Teddy, was born on 13 March this year. The birth was neither straightforward, nor especially complicated in clinical terms. Significant meconium in the waters meant that giving birth in the midwife-led unit was off the cards from the outset. Transverse shoulders led to forceps, an episiotomy, and a third degree tear, which in turn led to surgery. I have friends and colleagues—people whose stories are not mine to tell—who have had far more traumatic, and far simpler, births than this. Being born at the John Radcliffe hospital in Oxford at 9.15 pm (just after a shift change), meant that we had a midwife and two student midwives in the room, as well as two doctors to help with the birth and a paediatrician in case of complications from the meconium. I have never felt so looked after by the NHS (in the interests of full disclosure, one of the student midwives was temporarily diverted after my son was born by helping me sit down before I fainted).
Overnight and the next day, Teddy was showing signs of infection, which led to lumbar punctures, X-rays and antibiotics. Combined with my wife's surgery, this meant an extended stay in hospital, and difficulty getting started with feeding. Once again, we received a huge amount of support—from midwives, maternity support workers, and the hospital's infant feeding team, and, in the form of donated breast milk. Being able to supplement my son's feed, without switching so early on to formula, made a huge difference to him and to our family during that first week that we were in hospital. I have spent much of my adult life studying altruism and donative behaviour, but had never come across this extraordinary form of generosity.
The women who donated some of their precious breast milk are helping recipient children, including my son, without ever having met them. After we arrived home from hospital, I wrote a short piece talking about our experiences and the amazing gift we had received. The range of responses, from charities, donors and donated milk recipients, doctors, long-lost friends and professional rivals alike, was overwhelming.
The benefits of breast milk, ranging from improved health outcomes, lower risk of mortality, and greater cognitive development (Horwood et al, 2001; Isaacs et al, 2010), are widely known. Less widely studied and discussed are the benefits of donated breast milk.
Lucas and Cole (1990) conducted a randomised controlled trial with premature babies and found that donated breast milk reduced mortality among the 5% of these babies diagnosed with necrotising enterocolitis, helping to save perhaps 100 lives per year. Taken together, the benefits of donated breast milk for a large number of (especially premature) babies are substantial.
If we know the benefits of donated breast milk, we know remarkably little, in the scientific sense, about the supply (I have yet to find a single study in my own field of behavioural science that looks into the drivers of breast milk donation). Mainstream reporting focuses on two important factors: a supply of milk in excess of what is needed by the donor's own offspring, and a desire to help. One story of a woman in the USA, who donated 52 litres of milk (Leguizamon and Willingham, 2018), underlines these factors.
These stories give us only a partial picture of the underlying motivations that women experience when they decide to donate breast milk. We cannot say whether breast milk donations are similar to the donations of money (charitable giving), of time (volunteering), replenishing (blood) or fixed (organs) parts of ourselves. This is not purely an academic pursuit. Understanding the underlying reasons for donations is fascinating in itself, but it has a practical applications as well. By understanding the motivation, milk banks, midwives and others could increase the supply of life-giving milk by encouraging more women to donate, and help women who are already giving to continue to do so for longer. Just as importantly, an understanding of why people donate can help avoid making people (such as new mothers with low supply) feel guilty for not being able to (Andreoni et al, 2017).
I believe that Behavioural Science can help. Studies have shown that social information—letting people know that other people have donated (Huck and Rasul, 2011), or how much (Meer, 2011 —can increase the likelihood of donating. Seeing a particularly generous donor can increase others' donations by more than if they see someone who has donated a smaller amount (Smith et al, 2015)—this effect is even bigger if the person who made the large donation has chosen to be anonymous (Peacey and Sanders, 2014). Often, the person most likely to be successful in their appeal for a donation is a friend or colleague, not a charity themselves (Meer, 2011). Celebrity endorsements do not seem to work, at least not in the short term (Sanders, 2015).
Small gifts, given in advance of a donation, like a fridge magnet (Alpizar et al, 2008) can double how many people donate money but, although effective, giving people rewards for making a donation is often controversial (Lacetera et al, 2012).
People think that they give to help a cause, but more often respond most strongly to identifiable human beneficiaries of their donation, such as being able to visualise a particular person who will, or could, benefit (Small et al, 2007). Similarly, if they receive messages from people who benefited previously from a charity, fundraisers are more effective (Grant, 2008). Asking people to consider their own possible future needs, such as whether they might one day need an organ themselves, can get them to sign up to be organ donors (Harper et al, 2013).
We know all of this and more about why people donate, and what might make them more likely to donate or to donate more frequently. What we don't know is whether any of these lessons, or others, can be applied to breast milk donations. Consequently, I have begun a programme of research to identify the motivations of milk donors, and see if more women can be made aware of the opportunity to donate and to do so, to help more children like my son to benefit from this extraordinarily generous act.