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https://doi.org/10.1177/08903344231196113
Journal of Human Lactation
1 –13
© The Author(s) 2023
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DOI: 10.1177/08903344231196113
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Original Research
1196113JHLXXX10.1177/08903344231196113Journal of Human LactationOreg and Negev
research-article2023
Peer-to-Peer Human Milk-Sharing Among
Israeli Milk Donors: A Mixed-Methods
Study in the Land of Milk and Honey
Ayelet Oreg, PhD1 and Maya Negev, PhD2
Abstract
Background: Evidence is lacking on the phenomenon of peer-to-peer human milk-sharing in the Middle East, specifically,
in Israel.
Research Aims: This study aimed to uncover peer-to-peer human milk-sharing in Israel, learn about how and whether
donors engage in safe milk handling and storage practices, and assess knowledge about human milk and breastfeeding among
this milk-sharing population. We also aimed to investigate donors’ selectiveness in their decisions about to whom they donate
their milk and their perceptions about the sale and purchase of human milk.
Methods: We conducted a semi-structured online survey, including both closed- and open-ended questions and used mixed
methods to analyze responses descriptively. We used non-probability sampling to obtain a broad sample of human milk donors.
Results: Out of 250 completed surveys, most participants (87.2%, n = 218) reported engaging in safe milk-sharing practices
and were generally knowledgeable about the health risks associated with milk-sharing. Participant religiosity was associated
with somewhat lower hygiene practices (r = −0.15, p ≤ .05). Most of the participants (81.7%, n = 190) were against the sale of
human milk. Participants generally expressed no preference about the recipient of their milk, with some exceptions.
Conclusion: The milk-handling and storage practices of the participants in this study suggest a need to improve knowledge and
awareness of safe milk storage temperature and the importance of washing hands before pumping milk, particularly within the
religious sector. We propose that guidelines about safe milk-sharing practices be written and adopted by the Israeli Ministry of
Health, and communicated through pediatricians, family doctors, nurses in Mother and Child Clinics (In Hebrew: Tipat Halav),
and social media.
Keywords
breastfeeding, donor identity, food nutrition improvement, health risks, informal human milk sharing, Israel, milk sharing
practices, peer-to-peer human milk sharing
תוידוהי תוילארשי תומרות ברקב םא בלח יפותיש לע תושיג בלשמ רקחמ :שבדו בלח ץראב םא בלח יפותיש
ריצקת
.לארשיב םלועמ הרקחנ אל העפותה .ןוכיתה חרזמב םיילמרופ אל םא-בלח יפותיש תעפות לע רקחמ דואמ טעמ ונשי :עקר
תוקיטקרפ תא ןוחבל ,לארשיב )בלחה קנב ךרד אלש( םיילמרופ אל םא-בלח יפותיש תעפות תא ןוחבל יחכונה רקחמה תרטמ :רקחמה תורטמ
תדימ תא ונחב ,ףסונב .הקנהו םא-בלח יבגל בלח תומרות לש עדיה גוסו ףקיה תא ךירעהלו ,בואשה םאה-בלח לש האפקההו ןוסחאה ,לופיטה
.ןהלש בלחה תא רוכמל תורשפאה יבגל תומרותה לש ןהיתוסיפתו המורתה ינעמנ תריחבל עגונב תומרותה לש תויביטקלסה
תברעמ הטישב ונשמתשהו ,תורוגסו תוחותפ תולאש ונללכ ובש ,הצחמל-הנבומ יטנרטניא רקס ונכרע :תוטיש
ןווגמ םגדמל עיגהל ידכ תיתורבתסה יתלב המיגדב ונשמתשה .ירואית ןפואב תובושתה תא חתנל תנמ לע )MIXED METHODS( תושיג
.םא-בלח תומרות לש
םא-בלח ףותיש תוקיטקרפב שומיש לע וחוויד )88.3%( תופתתשמה תיברמ ,םיאלמ םינולאש 250 ךותמ :םיאצממ
תמאותמ התייה תופתתשמה לש תויתדה תמר .ולא תומורתב םיכורכה םינוכיסה יבגל תואנ עדי וניגפהו ,תוחוטב
ועיבה )n = 190, 81.7%( תופתתשמה תיברמ .)r = −.15, p ≤ .05( המורתה ךילהתב הנייגיה לע הדפקה םע תילילש
המורתה ינעמנל עגונב תופדעה ועיבה אל תופתתשמה ,ןפוד תואצוי רפסמ טעמל .םא-בלח רוכמל תורשפאל תודגנתה
תועדומהו עדיה תא רפשל ךרוצה לע םיעיבצמ רקחמה תופתתשמ לש םאה בלח ףותישו ןוסחאה תוקיטקרפ :תונקסמ
רסח היהש עדי ,בלחה תביאש ינפל םיידי תציחר תובישחלו ,בואש םא-בלחל תשרדנה ןוסחאה תרוטרפמט תדימ יבגל
תואירבה דרשמ לע .םא בלח יפותישל תוחוטב תוקיטקרפ יבגל תורורב תויחנה חסנל שי ,ףסונב .יתדה רזגמב רקיעב
תופיט תואפרמב תויחא ,םידליו החפשמ יאפור תועצמאב רוביצל ןתוא רשקתלו ,הלאה תויחנהה תא ץמאל ילארשיה
תיתרבחה הידמה הצורעבו ,הליהקב בלח
Back translation by: Ilana Chertok, PhD, MSN, RN, IBCLC and Adina Kopinsky, IBCLC
2 Journal of Human Lactation 00(0)
Background
Human milk is the optimal, most highly recommended,
source of nourishment for the infant )Cassidy et al., 2019(.
From the dawn of humanity, mothers have been engaged in
peer-to-peer human milk-sharing—feeding an infant with
human milk that is not from an infant’s biological parent, and
that is not shared commercially )Reyes-Foster et al., 2017(.
Peer-to-peer milk-sharing )also known as “informal milk-
sharing”( is typically reciprocal and is usually unpaid
)Peregoy et al., 2021; Thorley, 2008(, unlike wet nursing,
which, in some cases and throughout history, was a form of
exploitation of the female body during slavery )Cassidy et al.,
2019(. Studies have shown that peer-to-peer human milk-
sharing practices have changed since the invention of the
breast pump. In addition, the expansion of social media and
the internet play a major role in peer-to-peer sharing today
)Peregoy et al., 2021(. Recently, peer-to-peer milk-sharing
has become mostly an online sharing phenomenon )Palmquist
& Doehler, 2016; Peregoy et al., 2021; Thorley, 2012(.
The World Health Organization )WHO( classifies human
milk among a group of medical products of human origin
)MPHO( )Noël & Martin, 2015; World Health Organization
Task Force on Methods for the Natural Regulation of
Fertility, 1998(. These are “biological materials that are
derived wholly or in part from the human body and are
intended for clinical application” )Noël & Martin, 2015, p.
383(. Whereas all other MPHO )i.e., sperm, ovarian eggs, or
blood( have clear sharing regulations )e.g., donors must be
selected, tested and screened(, this is not the case with human
milk )Noël & Martin, 2015(. There are significant inconsis-
tencies in how human milk has been defined and how its
sharing has been regulated in milk banks )Klotz et al., 2022(.
Current applied classifications for human milk around the
world include human milk as a food, as a tissue, and as a
therapeutic good/medicine )Oreg & Appe, 2022(. Informal
sharing )e.g., online sharing( is not regulated )Cohen, 2018(.
This is a problem because sharing milk online involves
health risks given that the milk is not monitored or pasteur-
ized )Cassidy et al., 2019; Cohen, 2018(.
Milk can include contaminants, including viruses or bac-
teria that enter the milk through unclean pumps, poor bottle
hygiene, or improper handling and storage )Walker &
Armstrong 2012(. When human milk comes into contact
with foreign surfaces, common bacterial flora and microbial
species may be introduced via the collection apparatus. In
particular, contaminated pumps can easily become reservoirs
of bacterial contamination, especially after being used by
multiple people and when inadequately cleaned between
uses )Engür et al., 2014(. Thus, the appearance of pathogenic
bacteria and enterobacteria in human milk is common )Groer
et al., 2020(. In addition, neonatal infections have been
linked to contaminated human milk )Lewin et al., 2019(.
There is no evidence, however, that the COVID-19 virus is
infectious through breastfeeding )WHO, 2023( or through
contact with surfaces )Mitchell & Weinstein, 2020(.
Milk can become contaminated at any point along the
milk pathway, including its expression, collection )Boo et al.,
2001(, transport, storage, and handling )Human Milk
Banking Association of North America, 2011(. In a series of
case studies, Boo et al. )2001( examined the milk-expressing
practices of mothers of very low birthweight babies )<
1,501 g(. They found a high rate of pathogenic bacterial con-
tamination in expressed human milk, whether it was obtained
by pump, at home, or in the hospitals. Moreover, milk that is
shared without monitoring can be contaminated with sub-
stances, including alcohol, nicotine, medication, and other
contaminants )Arslanoglu et al., 2023; Keim et al., 2013,
2014(. Indeed, in 2005, the American Academy of Pediatrics
)AAP( published a statement discouraging parents from
feeding preterm infants’ fresh milk from unscreened donors
)Keim et al., 2013, 2014(.
The U.S. Food and Drug Administration also recom-
mends against feeding infants shared human milk that is
acquired directly from individuals or via the internet )Reyes-
Foster et al., 2017; U.S. Food and Drug Administration,
1The Louis and Gabi Weisfeld School of Social Work, Bar Ilan University, Ramat Gan, Israel
2School of Public Health, University of Haifa, Haifa, Israel
Date submitted: October 7, 2022; Date accepted: July 10, 2023.
Corresponding Author:
Ayelet Oreg, PhD, The Louis and Gabi Weisfeld School of Social Work, Bar-Ilan University, Ramat Gan, 5290002, Israel.
Email: ayelet.oreg@biu.ac.il
Key Messages
Peer-to-peer human milk sharing is rarely stud-
ied in geographical areas outside of North
America, Australia, and the United Kingdom.
This study is the first to explore the phenome-
non in the Middle East, specifically, in Israel.
Respondents generally reported safe practices
and were knowledgeable about health risks
associated with milk sharing. Donor religiosity
was positively associated with somewhat lower
hygiene practices.
This study highlights the need for guidelines to
improve knowledge and awareness of safe
milk-handling and storage practices in Israel,
particularly within the religious sector.
Oreg and Negev 3
2018(. In 2015, The European Milk Bank Association
)EMBA( and Human Milk Banking Association of North
America )HMBANA( issued a joint statement advising fami-
lies about the possible risks of buying or sharing human milk
obtained via the internet )European Milk Bank Association,
2015(. In that statement they “strongly discourage internet
mediated sharing or selling of breastmilk and fully endorse
the promotion of breastfeeding and donation of surplus
breastmilk to non-profit milk banks.” )Recommendations
section( The statement further advises “all parents to be
aware of the risks involved in feeding an infant with another
mother’s milk and before doing so to consult a qualified
healthcare professional such as a pediatrician, neonatologist
or hospital infant feeding specialist” )European Milk Bank
Association, 2015, Recommendations section(. Alongside
these recommendations, however, others have noted the pos-
sibility of engaging in milk sharing while practicing “risk
reduction” )e.g., Palmquist, 2020( that can substantially
reduce the contamination-related risks involved milk shar-
ing. Moreover, it should be acknowledged that, in many
cases, those who seek out human milk do not have alterna-
tives to informal routes of milk sharing, such as those who
live in locations that do not have milk banks.
Overall, the use of expressed human milk for feeding
infants is growing globally, both through peer-to-peer milk-
sharing and via commercial markets and derivative products
)Palmquist et al., 2019(. Between 2011 and 2013 an esti-
mated 170 social media groups were dedicated to milk-shar-
ing )Palmquist & Doehler, 2016(. These included Facebook
groups and groups on designated milk-sharing websites.
Little is known about the extent to which milk is informally
shared via the internet, and little is known about informal
human milk-sharing among families and friends within their
local U.S. communities )O’Sullivan et al., 2016(. Palmquist
and Doehler )2014( found that online milk-sharing in the
United States is particularly common among middle-income,
college-educated, White women. Perrin et al. )2014( esti-
mated in their study that more than 130,000 mothers partici-
pated in that year )2014( in online milk-sharing networks
around the world. In the same year, Gribble )2014( found
that tens of thousands of milk-sharing exchanges are con-
ducted worldwide through websites annually. A 2015 U.S.
study estimated that there were 13,000 online posts or adver-
tisements, annually, for milk-sharing via Facebook groups
and websites )Keim, et al., 2014(.
Informal peer-to-peer online human milk-sharing is rarely
studied in geographical areas outside the United States. This
study is the first to explore the phenomenon in Israel. Israel’s
first milk bank was established in August 2020; however, it
initially operated as a pilot and only in January 2021 did it
begin to operate and distribute milk to all of the hospitals in
the country )personal communication with the milk bank’s
manager, Sharron Bransburg-Zabary, January 2023(. Donating
to the milk bank was therefore not an option at the time of our
study. Before the new Israeli milk bank was established, the
only mode of exchanging human milk was through online
sharing or sharing in the community. Although there is no law
against it, human milk is not generally sold in Israel. Our aim
in this study was to uncover peer-to-peer human milk-sharing
in Israel, learn about how and whether donors engage in safe
milk handling and storage practices, and their knowledge
about health-related aspects of milk sharing and breastfeeding.
We also aimed to investigate donors’ selectiveness in their
decision about to whom they would donate their milk and their
perceptions about the sale and purchase of human milk.
Methods
Research Design
We conducted a semi-structured online survey, including
both closed- and open-ended questions and used mixed
methods to analyze responses descriptively. This allowed us
to quantify and gain insights into the participants’ extant
knowledge and attitudes about milk-sharing. We used non-
probability sampling to obtain a broad sample of human milk
donors. An invitation to participate in the study with a link to
the online questionnaire was published on Israeli milk-shar-
ing Facebook groups, breastfeeding mothers Facebook
groups, milk-sharing WhatsApp groups, and Israel’s only
milk-sharing website )Mama-Milk, a communal milk-shar-
ing platform in Hebrew(.
Our research questions were:
1. To what degree do Israeli human milk donors, who
donate via informal routes, engage in safe milk han-
dling and storage practices?
2. How knowledgeable are Israeli informal milk donors
with respect to the risks involved in milk-sharing and
breastfeeding?
3. What relationships are there between donors’
sociodemographic characteristics, their milk-related
knowledge and their milk extraction, handling, and
storage practices?
4. Are donors being selective in deciding to whom they
donate their milk? If so, is there a relationship
between donors’ sociodemographic characteristics
and their donation preferences?
5. What are the donors’ beliefs about possible monetary
or other compensation for their donated milk?
The study was approved by the Institutional Review Board
of the participation institution )IRB approval provided on
December 9th 2020, Protocol #522/20(.
Setting and Relevant Context
At the end of 2021, Israel’s population comprised 73.9%
Jews, 21.1% Arabs, and 5% Christians, Druze and others
)Israel Central Bureau of Statistics, 2021(. Israeli culture is
4 Journal of Human Lactation 00(0)
very diverse and is influenced both by its Middle-Eastern
heritage and Western influences. It includes the values and
practices of Jews, Muslims, Christians, and others, ranging
from highly religious to entirely secular. Even within the
Jewish population, the diversity is substantial, with respect
to variables like the degree of religiosity and ethnic back-
ground. These cultural attributes contribute to the unique
nature of bodily gifting practices in Israel )Boas, 2022(.
Situating human milk donation within the realm of body
organ and fluid donations, Israel is among the most gener-
ous countries in the world, and the number of organ donors
is constantly increasing )Boas, 2022; Global Observatory
on Donation and Transplantation, 2021; National
Transplant Center, 2020(. In particular, Israel is a world
leader in live-donor kidney donations )Kurleto et al., 2020;
National Transplant Center, 2020(. Between 2007 and
2018, kidney transplants from live donors increased by
339% )Kurleto et al., 2020(. In 2020, 67% of all living
kidney donations in Israel were from living volunteers who
did not know the recipients, which is in contrast to 7% in
the United States )Boas, 2022(. A WHO report listed
Israel's mean annual number of live kidney donors as being
just over 30 people per million, which is double the ratio in
the United States )Global Observatory on Donation and
Transplantation, 2021(. A study among Jewish Israeli live
kidney donors found that the donor’s motives were “over-
whelmingly altruistic.”
In addition, until 2010 a total of 561,071 Israelis had
signed an Adi donor card )Adi is the name of Israel’s
national transplant center(, expressing their willingness to
donate their organs after death, compared to 996,520 Israelis
who had signed a donor card by 2020 )National Transplant
Center, 2020(. Similarly, there has been a constant increase
in blood donations in Israel )Magen David Adom, 2022(.
Human milk-sharing is part of a larger phenomenon of
donating bodily organs and fluids. In Israel, similar to other
countries around the world )e.g., U.S., U.K., France(, there
are no restrictions on the sale and purchase of human milk
)Oreg & Appe, 2022(. Human milk is nevertheless not typi-
cally sold in Israel.
Israel’s health system tends to be supportive of breastfeeding
)Zimmerman et al., 2022(. By law, every Israeli resident must
be registered with one of four Health Maintenance Organizations.
All citizens are automatically covered by health insurance )paid
through taxes; Zimmerman et al., 2022(. The Ministry of
Health’s guidelines direct hospital staff to provide mothers with
breastfeeding assessments by breastfeeding counselors soon
after giving birth )Zimmerman et al., 2022(, and approximately
90% of Israeli mothers initiate breastfeeding. However, the rate
of exclusive breastfeeding drops sharply in the early postnatal
period )Zimmerman et al., 2022(. This may be related to par-
ents’ perceptions of insufficient support from medical staff in
the later postpartum period. Medical staff have been viewed as
unable to provide sufficient assistance in dealing with the chal-
lenges involved in breastfeeding )Blitman et al., 2022(.
Sample
Our focus in the current study was on Israeli Jewish donors
who donate milk via online and social media platforms given
that, at present, the Arab population in Israel does not typi-
cally use those or any alternative milk-sharing platforms.
Participation in the study was on a voluntary basis, and, as
noted above, participants were recruited through non-proba-
bility sampling. The link to the survey was distributed on
April 6, 2021, and the link remained active until July 9, 2021,
at which point it was clear that we were not receiving addi-
tional responses to the survey. Of the 348 respondents who
clicked the survey link, 250 completed the survey. The inclu-
sion criteria were a response of “Yes” to the question: “Have
you donated human milk in the last 4 years?”
Measurement
Participant demographics were measured through questions
about their age, number of children, levels of education and
religiosity, political view, income, profession, and the size of
the town they live in. Participants’ religiosity was assessed
using a Hebrew version of Chamada’s )2002( 3-item scale:
“To what degree do you believe in your religious values?”
“To what degree do you behave in accordance with your reli-
gious values?” and “To what extent do you practice your reli-
gion?” The scale’s internal reliability )Cronbach’s alpha( in
the present study was 0.95. Participants’ political views were
assessed using a question about their position ranging from
left-wing to right-wing, using these five response options:
left, left-center, center, center-right, right. Larger values on
this variable reflect more right-wing views.
Milk handling practices were assessed with the five items
used by Reyes-Foster et al. )2017( for assessing participants’
milk handling and storage practices. Items were translated to
Hebrew using a translation-back-translation process and
respondents chose from a five-option scale from always to
never. Knowledge about health-related risks in milk sharing
and breastfeeding were assessed with 16 items, composed
for the present study. Eight items pertained to knowledge
about the effects that milk handling procedures can have on
the milk, and another eight concerned knowledge about the
substances that can be transmitted through the milk. Before
administering the items, we conducted a pilot study to ensure
items’ readability. We sent the draft survey to 10 people,
including donors, recipients, and subject-matter experts, who
provided feedback on the quality and clarity of the questions,
after which we revised the items to improve their clarity.
Preferences about the donation’s recipient were assessed
through six questions designed for the present study.
Response options for this scale were on a 5-point Likert
scale, ranging from 1 “do not agree at all” to 5 “always
agree.” To assess the attitude toward the sale of milk we used
five items, developed for the present study. In addition, we
asked the open-ended question: “Should Israeli law permit
Oreg and Negev 5
the sale and purchase of human milk? )yes/no(,” followed by
the questions, “if Yes, why?” and “if No, why not?”
Data Collection
The survey, in Hebrew, was distributed online between April
and July 2021, at the peak of the global COVID-19 pan-
demic, during and between national lockdowns, using
Qualtrics XM software to obtain rapid responses. Online
informed consent was obtained from all participants in the
opening section of the survey. Surveys were anonymous and
all data were kept confidential on the researchers’ computers,
protected by a password.
Data Analysis
Frequencies, means, and standard deviations were calculated
for sample demographics, and then for responses to the ques-
tions pertaining to Research Questions 1 and 2 about partici-
pants’ milk handling practices and milk-related knowledge.
We then calculated Spearman correlations to address
Research Questions 3 and 4, pertaining to the relationships
between participants’ demographics and their milk-related
knowledge, practices, and preferences of donation recipi-
ents. To address Research Question 5 about participants’ atti-
tudes toward the sale of milk, we calculated frequencies of
responses to the questions about participants’ beliefs about
compensation for donating human milk, and identified main
themes of responses to the open-ended questions. In addi-
tion, to retest Research Question 3, we conducted logistic
regressions with demographic variables )education, religios-
ity, income, profession, and mother’s age( as predictors of
knowledge about the effects of milk-handling procedures,
knowledge about the substances that can be transmitted
through milk, and milk-handling and storage practices. Level
of knowledge was classified as “high” for those who pro-
vided six correct answers or more )out of eight knowledge
statements(; 34% )n = 85( were thus classified. All others
were classified as “low.” For the logistic regression predict-
ing milk-handling and storage practices, we distinguished
between “high” and “low” safe hygiene practices, by classi-
fying those who responded “always” or “usually” to all five
of the practices we asked about to the “high” group, and all
others into the “low” group )57%, n = 143( were classified
into the “high” safe hygiene practices category. The open-
ended answers to the question about the sale of human milk
were content analyzed )Hsieh & Shannon, 2005( for themes
that emerged in favor of and against selling milk.
Results
Most of the participants were 26–33 years-old, with diverse
religiosity and political views, and 44.3% )n = 110( had an
income that was “above average” )Table 1(. About 50%
)n = 121( worked in a caregiving profession )e.g., social
worker, nurse(. Beyond the data reported in Table 1, the
mean number of children was 2.1 )SD = 0.9(.
Participants’ Handling and Storage Practices and
Milk-Related Knowledge
Only about half )57.2%, n = 143( of the participants in our
study reported “always” engaging in all five milk-handling
and storage practices identified as safe )Table 2(. Another
30.0% )n = 75( responded “always” about four of the five
practices. The practice engaged in least frequently was that
of washing hands. A much greater degree of care was reported
with respect to the handling of the milk and pumping equip-
ment )Table 2(
The mean number of correct responses to the eight ques-
tions about the effects of milk-handling procedures in the
portion of the survey related to milk-related knowledge was
4.9 )SD = 1.4(, and the mean number of correct responses to
the eight questions about milk-transmitted substances was
5.4 )SD = 1.0(.
Most participants were aware that certain medication
should not be taken while breastfeeding and sharing milk,
and knew about the potential for contamination from unster-
ilized pumps. About half knew that pumped milk could con-
tain viruses and bacteria. Only a quarter knew that human
milk could be pasteurized at home. Participants were gener-
ally knowledgeable about milk-transmitted substances, with
the exception that less than half knew that HIV could be
transmitted through human milk. In addition, most partici-
pants were incorrect in believing that their religious dietary
practices )i.e., eating kosher( influenced whether their milk
was kosher )Table 3(.
Relationships Between Participant Demographics
and Milk-Sharing Knowledge and Practices
Religiosity was the only demographic variable with a signifi-
cant correlation to milk-sharing knowledge and practices
)Table 4(. The more religious participants were, the less
informed they were about the health-related impact of how
the milk and pumps were handled.
The only significant variable emerging from the logistic
regression for predicting knowledge about the effects of
milk-handling procedures was profession. The odds of
respondents with therapeutic, care-giving professions to
have a high level of knowledge were 2.28 times higher than
for those with non-care-giving professions )Table 5(.
With respect to knowledge about milk-transmitted sub-
stances, the only tested demographic variable that was sig-
nificantly )positively( associated with this knowledge was
settlement size )Table 4(. In the logistic regression for pre-
dicting knowledge about milk-transmitted substances, none
of the demographic variables were significant. Finally, in the
logistic regression for predicting knowledge about milk-han-
dling and storage practices, the only significant predictor was
6 Journal of Human Lactation 00(0)
religiosity )Table 6(. A higher level of religiosity was associ-
ated with a 25% lower chance of safe hygiene practices.
Donation Recipient Preferences
When choosing to whom to donate their milk, 94% )n = 235(
of the participants reported that they had no preference with
respect to the recipient’s religion or sociodemographic sta-
tus; however, with respect to family structure, a quarter of
them )n = 63( preferred not to donate to a family with two
fathers. The correlations between level of religiosity and
donation recipient preferences )Supplemental Table 1(
showed that the more religious the respondent, the stronger
her preference for donating her milk to a recipient from the
same religion, namely, a Jewish family, and the less inter-
ested she was in donating her milk to a family with two
fathers. Similarly, the more right-wing the woman’s views
were, the stronger her preference for donating to Jewish
recipients )Supplemental Table 2(.
Participant Attitudes to the Sale of Human Milk
Most )94%, n = 234( of the participants were opposed to
receiving monetary or other compensation for their donation
)Supplemental Table 3(. Furthermore, over 80% )n = 190( of
the participants believed that the sale of human milk should
be forbidden in Israel.
Respondents gave several reasons for and against permitting
the sale and purchase of human milk in Israel. Six main reasons
were given in favor of permitting sale, including increasing the
supply for recipients and improving quality control )Table 7(,
and six main reasons were given against permitting sale, includ-
ing ethical issues and risk of fraud )Table 8(.
Discussion
Overall, the characteristics of the Israeli milk donors in our
sample were similar to those of other populations around the
world. Participants in this survey were mostly white,
belonged to the middle class, and had tertiary education
)Cohen, 2018; Gerstein Pineau, 2011; Palmquist & Doehler,
Table 1. Demographics of Study Participants (N = 250).
Category n (%)
Mother’s age (years)
18–25 10 (4.0)
26–33 129 (51.6)
34–40 94 (37.6)
41–50 16 (6.4)
Age of donor’s infant at time of donation (months)
1< 6 43 (17.2)
≥ 6 and <12 54 (21.6)
≥12 and < 18 55 (22.0)
18+98 (39.2)
Level of religiosity (1-5)
Low (≥ 1 and < 2) 65 (26.0)
Low-Medium (≥ 2 and < 3) 54 (21.6)
Medium-High (≥ 3 and < 4) 70 (28.0)
High (≥ 4) 61 (24.4)
Level of education
High school diploma 20 (8.0)
Bachelor’s degree 126 (50.4)
Master’s and PhD 100 (40.0)
Political view
Left 40 (16.0)
Left-center 47 (18.8)
Center 42 (16.8)
Center-right 46 (18.4)
Right 55 (22.0)
Incomea
Below average 96 (38.4)
Average 42 (16.8)
Above average 110 (44.0)
Profession (open question)b
Therapeutic professions 121 (48.4)
Non-therapeutic professions 117 (46.8)
Size of settlement 59 (23.6)
Rural settlement or kibbutzc
Small-medium size town ( < 200,000 residents) 99 (39.6)
Large town ( > 200,000 residents) 78 (31.2)
Note. Missing: mother’s age = 1; level of education = 4; political view = 8;
income = 2; profession = 12; size of settlement = 14.
aBecause respondents are often sensitive about questions concerning
their income, we restricted our question about income to the categories
of “below average,” “average,” and “above average.”
bTherapeutic professions = nurse, social worker, doctor, lactation
consultant, doula, alternative medicine therapist, school counsellor, and
other caretaking professional roles; non-therapeutic professions = hi-tech,
engineer, accountant, architect, and similar professional roles not defined
by caretaking of others.
cKibbutz refers to small Israeli settlements, traditionally based on
agriculture.
Table 2. Engagement in Safe Milk-Handling and Storage Practices
(N = 250).
Item n (%)
Hands must be washed prior to expressing or
pumping milk
200 (80.0)
Use containers and pumping equipment that have
been washed in hot water or sanitized
240 (96.0)
Milk should not be left out at room temperature
for more than 8 hours
236 (94.8)
Milk should not be frozen in household
refrigerator/freezer for more than 6 months
208 (83.5)
Milk should be transported on ice 222 (89.5)
Frequency of ‘always’ responses practice questions
0 or 1 3 (1.2)
2 or 3 29 (11.6)
4 75 (30.0)
5 143 (57.2)
Note. Items taken from Reyes-Foster et al. (2017). If participants
responded “always” or “often” out of a scale that also included
“sometimes,” “rarely,” or “never,” their response was considered a
positive response to the designated behavior.
Oreg and Negev 7
2016( The finding that over half of the participants were
from caregiving professions was also similar to previous
findings on the characteristics of participants to non-profit
human milk banks in North America )Oreg & Appe, 2020(.
Donors Milk-Handling and Storage Practices
Most participants in our study reported that they washed
their hands thoroughly before handling milk, which is con-
sistent with previous studies in the United States, where most
of the research on peer-to-peer milk sharing has been con-
ducted. For example, in a study by Reyes-Foster et al. )2017(,
82.3% of the respondents reported that they always washed
their hands before handling milk. In contrast, lower rates of
just over 50% were found in a study of 97 milk donors in
North America, Europe, Oceania, and Asia )Gribble, 2014(.
In our current study we expected a higher rate of hand wash-
ing, because the data were collected during the COVID-19
pandemic, and, for part of the study timeline, Israel was
experiencing a peak in COVID-19. During this period, the
Ministry of Health and the government broadcasted recom-
mendations throughout the day regarding hand washing and
the importance of hand and body hygiene, irrespective of
milk pumping. Over all of the e-communication channels,
the subject of hand washing was a central issue. Nevertheless,
we found that the message was not fully implemented.
Table 3. Knowledge of the Risks Involved in Milk Sharing, and General Knowledge about Human Milk and Breastfeeding (N = 250).
Answered correctly n (%)
Knowledge about the effects of milk-handling procedures
1. Pumped human milk can contain disease-bearing viruses and bacteria (correct answer: true) 130 (52.6)
2. The hygiene of the donor mother’s hands and body affects milk quality (correct answer: true) 154 (62.4)
3. The pump used by the milk donor can transfer bacteria and viruses (correct answer: true) 228 (91.9)
4. Some medicines are forbidden when breastfeeding and donating milk (correct answer: true) 249 (99.6)
5. COVID-19 can be transmitted by surfaces such as milk pumps / milk bags / milk pump motor
(correct answer: false)
148 (60.2)
6. There are techniques for pasteurizing human milk at home (correct answer: true) 60 (25.0)
7. The donation route (donation via a milk bank / online donation / direct donation from a friend or
relative) does not affect milk quality (correct answer: false)
100 (40.7)
8. Human milk can be contaminated even if it is frozen and stored in the freezer (correct answer:
true)
140 (57.1)
Knowledge about milk-transmitted substances
1. Alcohol is transferred through human milk (correct answer: true) 243 (97.6)
2. The donor’s nutrition affects her milk quality (correct answer: true) 163 (65.2)
3. HIV can be transmitted through human milk (correct answer: true) 117 (47.6)
4. COVID-19 can be transmitted through human milk (correct answer: false) 15 (6.0)
5. Seasonal viruses such as influenza can be transmitted through human milk (correct answer: false) 238 (95.6)
6. If the donor does not keep kosher or halal then her milk will not be kosher (correct answer: false) 214 (87.0)
7. If the donor smokes, the nicotine is transferred through her milk (correct answer: true) 216 (87.5)
8. If the donor does not smoke, but lives in a smoking environment, the nicotine is transferred
through her milk (correct answer: true)
144 (58.1)
Note. This is an author-created scale.
Tables 4. Spearman Correlations Between Donor Demographics and Donors’ Milk-Sharing Knowledge and Practices (N = 217).
Knowledge about effects of
milk-handling practices
Knowledge about milk-
transmitted substances
Milk-handling and
storage practices
Degree of religiosity -0.052 0.025 -0.145*
Level of education 0.013 -0.033 -0.045
Income level -0.016 0.046 0.074
Size of settlement 0.083 0.130* 0.003
Note. The score for knowledge about the effects of milk-handling procedures was calculated by taking the average of the responses to the first eight
knowledge items in Table 3. The score for knowledge about milk-transmitted substances was calculated by taking the average of the responses to the
latter eight knowledge items in Table 3. The score for milk-handling and storage practices was calculated by calculating the average of the five practice
items in Table 2.
*p ≤ 0.05.
8 Journal of Human Lactation 00(0)
Almost all of the participants in our sample reported that
their pumping equipment and storage containers were used
only after they had been washed in hot water or sanitized.
This finding is different from that found in studies in the
United States, which revealed a much lower rate. For exam-
ple, Reyes-Foster et al. )2017( found that only 78.9% of the
respondents reported that they sanitized their pumping
equipment. However, among our results, milk-sharing
knowledge and safe milk-handling practices tended to be
lower among the more religious participants. Further
research, specifically with the religious community in Israel,
could be conducted to uncover the barriers to safe health
practices specific to this community.
We also found differences between Israeli donors and
North American donors with respect to storage of the milk
at room temperature. In a study of U.S. mothers, Labiner-
Wolfe and Fein )2013( specified that “room temperature
recommendations generally range from 3 to 8 hours,
depending on the cleanliness of the conditions under which
the milk was collected, and extended times are acceptable
in cold rooms” )p. 2(. In the present study, about 5% of
Israeli participants reported that they left the pumped milk
at room temperature for more than 8 hours, rather than
refrigerate it, compared to 1.5% of American donors in the
study by Reyes-Foster et al. )2017(. Similarly, Palmquist
)2020(, in her U.S. study, noted that “over 95% of the
respondents either never stored their milk at room tempera-
ture or did so for < 4 hours. Fewer than 1% left their
pumped milk at room temperature for > 8 hours” )p. 3(. In
Israel, located in the Middle East, adjacent to the
Mediterranean Sea, temperatures are relatively high
throughout the year and very high in the summer. This latter
finding is therefore disconcerting, as it endangers both milk
quality and infant health.
Regarding the practice of freezing milk, here, too, there
was a notable difference between Israeli donors and U.S.
donors. Whereas most Israeli participants stored their milk in
the family freezer for > 6 months, only 8.5% of American
participants did this )Reyes-Foster et al., 2017(. Similarly,
Labiner-Wolfe and Fein )2013( found that “most of the
respondents store their human milk within generally recom-
mended timeframes” )p. 4(. In Israel it is not possible to send
milk by post or courier service; therefore, all informal milk-
sharing takes place directly between donors and recipients.
All sharing meetings take place face-to-face. We found that
90% of participants made sure to transfer the donated milk to
the recipient while chilled on ice. This is in contrast to 54.4%
of American participants in the study by Reyes-Foster et al.
)2017(. It is reasonable to assume that with respect to face-
to-face sharing, the mutual responsibility and feeling of com-
mitment created between the donor and the recipient carries
great importance.
Table 5. Logistic Regression Using and Outcome of Knowledge About Effects of Milk-Handling Procedures as a Function of
Demographic Variables (N = 220).
Independent variables OR
95% CI
pLL UL
Education 1.17 0.72 1.93 0.525
Religiosity 0.85 0.66 1.08 0.185
Income 0.95 0.66 1.35 0.758
Therapeutic profession 2.28 1.24 4.20 0.008
Mother’s age (in years) 0.72 0.56 1.15 0.169
Note. Level of knowledge was dichotomized so that “high” included participants (34%, n = 85) who provided six correct answers or more out of
eight knowledge statements (see Table 3). All others were classified as “low.” Models: Profession defined as therapeutic (ref) versus non-therapeutic.
Education, religiosity, income, and mother’s age were used in individual models as continuous variables. LL = lower limit, UL = upper limit.
Table 6. Logistic Regression of Milk-Handling and Storage
Practices as a Function of Demographic Variables and Knowledge
About the Effects of Milk-Handling Practices and Milk-
Transmitted Substances (N = 217).
Independent variables OR
95% CI
pLL UL
Education 0.75 0.47 1.22 0.249
Religiosity 0.75 0.59 0.95 0.019
Income 1.29 0.91 1.83 0.146
Profession 0.91 0.50 1.63 0.739
Mother’s age (in years) 0.95 0.62 1.48 0.834
Knowledge about effects of
milk-handling procedures
1.23 0.68 2.24 0.495
Knowledge about milk-
transmitted substances
0.95 0.55 1.66 0.859
Note. Models: safe hygiene dichotomized so that high included participants
(57%, n = 143) who responded “always” or “usually” to all five the
practices, all other participants were designated as “low”; reference
group for profession set as non-therapeutic professions; education,
religiosity, income, and mother’s age were used in models as continuous
variables the score for knowledge about the effects of milk-handling
procedures was calculated by taking the average of the responses to the
first eight knowledge items in Table 3; the score for knowledge about
milk-transmitted substances was calculated by taking the average of the
responses to the latter eight knowledge items in Table 3. LL = lower limit;
UL = upper limit.
Oreg and Negev 9
Table 7. Donors’ Reasons in Favor of Permitting the Sale of Human Milk in Israel and Explanations for Their Responses (N = 38).
Reasons to permit the sale of human milk Example of an open-ended answer n (%)
1. Sale of human milk will encourage women to sell and increase
the supply, emphasizing the fact that human milk is better than
baby formula so it’s good that it will be possible to sell it. Supply
and demand
Yes, because there are many babies that need
human milk and often a donor cannot be found
18 (47.4)
2. It will enable control and supervision of the quality of the milk
and its sharing. It will be legal like a sperm bank.
Yes, because then the market will be better
controlled and parents will be able to choose
whether to give their child baby formula or human
milk
5 (13.2)
3. Sale of human milk is part of a woman’s right to her own body. Why not? If a woman wants to sell and there is
someone willing to pay, then it’s her private issue.
3 (7.9)
4. Pumping is hard work that deserves monetary compensation. Being able to sell the milk will recompense the
woman for the time it takes to pump (not for the
milk or the bags or the transport), and this might
encourage women who can donate to continue
donating.
4 (10.5)
5. Human milk is baby food and its sale should be permitted, just
like baby formula
To give women the option to choose, just like they
have the option to choose baby formula
5 (13.2)
6. Why not? I don’t see any reason why not. 3 (7.9)
Note. Qualitative content analysis of the answers to an open-ended question about the reasons in favor of the sale of human milk.
Table 8. Donors’ Reasons Against Permitting the Sale of Human Milk in Israel and Explanations for Their Responses (N = 158).
Reasons to forbid the sale of human milk Example of an open-ended answer n (%)
1. The value of giving / altruism / organ trading
is unethical / “human milk is given from the
heart”
So as not to commercialize the magic
Like blood, it’s something the human body produces and it doesn’t seem
ethical to receive payment for it.
Breastfeeding and human milk are giving, in my opinion, to your baby
or someone else’s. Pure, altruistic giving. Turning human milk into a
product that is bought with money hurts the aim in my opinion and
hurts me.
85 (53.8)
2. The problem of controlling milk quality; an
opportunity for exploitation and fraud (such
as diluting milk with water); an opportunity
for lawsuits
Legislation and sale of milk will make the issue very political and
encourage greed and problematic trade, leading to the need for
legislation and a potential black market.
It’s problematic with respect to disease transmission and requires
serious control. It may also lead low-income earners who require milk
into a problematic situation and will of course reduce donations
25 (15.8)
3. No status equality; an opportunity for
exploitation of women’s bodies; an
opportunity for physiological harm to women
It’s my first instinct, that there should be no discrimination in the
provision of human milk based on financial considerations
This may cause women to withhold milk from their babies in order to
sell it due to a bad financial situation. This is extreme but there are
stages to the process. It reminds me of prostitution. Sorry if I’m not
being clear enough.
It will cause exploitation of women.
42 (26.6)
4. A mother who donates enjoys better health
because of the pumping. She does not need
monetary compensation. She could receive
compensation for the milk bags, but no more
than that.
The concern that they will dilute or add substances in order to increase
the amount of milk, a concern regarding withholding of information
regarding medications and state of health.
2 (1.3)
5. Sale of human milk should be forbidden to
body builders; donation only to babies.
I think that milk donations should be to babies only and not to adults for
bodybuilding or other reasons.
1 (0.6)
6. Consider the idea strange/indifferent Like blood donation, the recipients usually need the milk for health
purposes, so it’s not logical in my opinion that the needy should have
to pay. But maybe there could be some kind of participation fee? I
don’t know; it’s a strange idea.
3 (1.9)
Note. Qualitative content analysis of the answers to an open-ended question about the reasons in favor of the sale of human milk.
10 Journal of Human Lactation 00(0)
Donors’ Identities, and Their Attitudes Toward
the Sale and Purchase of Milk
Among the main motives for human milk donation is the
desire to do good, help others, save lives and foster a sense of
solidarity, all of which are linked with milk donors’ identities
)Oreg & Appe, 2020; Palmquist, 2020(. Most Israeli partici-
pants in the present study reported that they had no prefer-
ence for donating specifically to a family of similar religion,
origin, or socioeconomic status. Consistent with the notions
of solidarity and altruistic motives, our participants were not
selective in choosing to whom to donate. Nevertheless, cor-
relations between level of religiosity, namely, religious iden-
tity, and recipient preferences, indicated that the more
religious )religious identity(, and the more right-wing the
participant )political identity(, the stronger was her prefer-
ence to donate specifically to Jewish recipients. Surprisingly,
and in somewhat of a contradiction to the unifying declara-
tion about “donating universally” to all those in need, the
descriptive statistics revealed that the more religious the par-
ticipant, the weaker was her willingness to donate her milk to
a family with two fathers. This finding can be explained by
the conservative value system of those religious donors,
which highlights traditional family values. Interestingly,
although 94% participants reported no preference with
respect to the recipient’s religion, socioeconomic status, and
ethnic background, 25% declared that they prefer not to
donate to a family with two fathers. This raises interesting
questions for future research about the boundaries of solidar-
ity and giving in the Israeli context.
Professional Identity
Half of the participants identified as being in caregiving
professions, which is an interesting finding compared to a
previous study that explored identities of human milk
donors to non-profit milk banks in North America )Oreg &
Appe, 2020(. Among the donors to HMBANA, the profes-
sional caregiver was identified as a dominant identity in the
motive for donating milk. However, in the same study
)Oreg & Appe, 2020(, the reason for most donors having
caregiving professional identities )including doctors,
nurses, breastfeeding consultants, and social workers( was
related to the fact that the milk banks were all located in
hospitals. Therefore, some of the donors were exposed to
the needs of hospitalized preterm babies for human milk on
a daily basis. Their motive for donating was explained )in
addition to altruism and solidarity with other mothers and
infants( by their daily proximity and awareness of needs.
Interestingly, in the present study, all participants donated
via online platforms, and had no prior acquaintance with
the recipients. The fact that about half of the Israeli partici-
pants were from caregiving professions can explain their
self-identity as helpers and givers driving their donation
even when they had never met the recipients. This
self-identification can be explained by the identity theory
)Charng et al., 1988(, which suggests that people take on a
variety of identities in the act of giving.
Religiosity as a Barrier to Human Milk-Sharing
Sharing milk carries both symbolic and tangible meanings,
as can be demonstrated by the issue of religiosity and milk.
A unique issue for the Israeli sample is the issue of keeping
kosher, leading 87% of participants to mistakenly believe
that donors’ eating habits affect the kosher status of their
milk. In practice, human milk is neither "kosher" or "not
kosher,” and is allowed to be consumed without any hal-
akhic )i.e., Jewish law( restrictions, except for a restriction
related to pumping milk, which is generally considered a
prohibited act on Shabbat )the Jewish Sabbath(. These find-
ings can be seen not only as a misunderstanding or misinter-
pretation of Jewish law, but as part of the symbolism of
human milk, and the attributes that are ascribed to human
milk. The donor’s lifestyle, and whether they are practicing
Jewish law or not, symbolically affect the “quality” of their
milk and its various components.
This finding also connects to the range of identities that
comprise donors’ identities and the meanings that donors and
recipients give to these identities. Human milk is “colored” by
the donor’s identity, and we must ask whether we can symboli-
cally differentiate between the donor and her milk. In this
sense, peer-to-peer milk-sharing enables a better personal
match between donor and recipient preferences. The issue of
kosher food consumption has far-reaching consequences with
respect to recruiting donors to the new Israel Milk Bank; to
date, approximately 1 year after its establishment, ultra-Ortho-
dox women are not donating to the milk bank, and ultra-Ortho-
dox babies do not feed on milk from the milk bank, due to
apparent halakhic issues )Israeli milk bank manager, Sharron
Bransburg-Zabary, personal communication, March 2022(.
Opposition to the Sale and Purchase of Human
Milk
The unique contribution of the present study is that 97.2% of
Israeli participants thought that milk donors should not
receive monetary compensation for their donation.
Furthermore, 81% believed that the sale of human milk
should be illegal. From the participants’ answers to the
open-ended questions about compensating human milk
donors )Supplemental Table 3(, and their reasons for and
against the sale of milk )Tables 7 and 8(, it seems that the
participants viewed milk donation as an altruistic act, attrib-
uting a symbolism to milk beyond its nutritional value.
Similarly, Gribble and Hausman )2012( argue that milk-
sharing is more than simply a means to feed an infant, and is
a symbiotic relationship between mothers, babies, and oth-
ers. Further attitudes regarding the sale of human milk
Oreg and Negev 11
reported by the study participants demonstrated the strong
feelings of mutual responsibility of the donors towards the
recipient families, particularly to those who cannot produce
enough of their own milk, as well as concerns regarding the
exploitation of women and the safety of the milk. These
concerns are in line with similar findings from the literature
)O’Sullivan et al., 2018(.
Limitations
Most of the milk-sharing in Israel takes place within the sec-
ular community and religious Zionist Facebook groups, one
main website, and WhatsApp groups. However, ultra-Ortho-
dox Jewish donors were not represented in our sample, as
they do not use the internet or smart phones. They have their
own local community group )g’mach( for milk-sharing. This
study took place during the first wave of the COVID-19 pan-
demic and the questionnaire was distributed during and in
between quarantines. Therefore, we could not reach those
groups within the ultra-Orthodox communities.
Another limitation relates to the methodology. A survey
cannot determine whether the reporting corresponds to actual
practice and is necessarily biased by selection due to the
nature of recruitment. Reyes-Foster et al. )2017( pointed out
that there is a social stigma attached to peer-to-peer milk-
sharing. However, although we are not familiar with the
extent of the social stigma in Israel, it is nevertheless possi-
ble that participants in this survey reported idealized prac-
tices. In addition, it is reasonable to assume some level of
social desirability to reporting “good” practices. In addition,
although the items we used in our study are closely aligned
with the subject matter we wished to assess, most of them
have not been validated in previous studies. Additional
research would thus be valuable for assessing the validity of
the new measures we used.
Conclusion
The milk-handling and storage practices of the participants
who participated in this study reveal the need to improve
knowledge and awareness of safe milk storage temperature
and the importance of washing hands before pumping
milk. We propose that guidelines about safe milk-sharing
practices be written and adopted by the Israeli Ministry of
Health, and communicated through pediatricians, family
doctors, nurses in Mother and Child Clinics )Tipat Halav(,
and in the social media. These kinds of guidelines will
hopefully lead to improved milk pumping and storage
practices and improved health and nutrition. Furthermore,
in light of the willingness of many participants to share
their milk unselectively, future research should focus on
uncovering the boundaries of solidarity and giving in the
Israeli context, which is a largely traditional society with
conservative values.
Acknowledgments
We thank Sharron Bransburg-Zabary for her advice and feedback
on our study, and the editor and anonymous reviewers for their very
helpful and constructive feedback on earlier versions of this
manuscript.
Author Contributions
Ayelet Oreg: Conceptualization; Data curation; Formal analysis;
Funding acquisition; Investigation; Methodology; Project adminis-
tration; Writing – original draft; Writing – review & editing.
Maya Negev: Conceptualization; Data curation; Formal analysis;
Investigation; Methodology; Software; Writing – review &
editing.
Disclosures and Conflicts of Interest
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iDs
Ayelet Oreg https://orcid.org/0000-0003-4859-7961
Maya Negev https://orcid.org/0000-0002-5523-3210
Supplemental Material
Supplementary Material may be found in the “Supplemental mate-
rial” tab in the online version of this article.
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