Liseane Morosini (Radis Magazine)
Not every pregnancy is the same, as Jecita Pereira Clares knows, who had no complications with the birth of her first child and then faced a premature birth with her second. At 25 weeks, Benjamin was born weighing 750 grams and Jecita experienced the emotional rollercoaster common to mothers with children in intensive care units.
When Radis spoke to her in the Milk Bank room at the Taguatinga Regional Hospital (HRT) in the Federal District, she was carrying Benjamin on her chest in the kangaroo position. Skin-to-skin contact with the mother brings numerous benefits for both – among them, stimulating breastfeeding. "It is a different experience. I didn't even know about this world of premature babies: I got to know it through living," she said, smiling.
Benjamin was tube-fed with milk supplied by the Human Milk Bank (BLH) at the Taguatinga Hospital, as Jecita was not yet producing milk. In this process called translactation, in which a probe close to the nipple delivers human milk, the mother made gentle movements with the baby's mouth to latch on the breast. Of the 1 ml of breast milk that Benjamin received at birth, he was consuming 35 ml a day after 73 days in hospital.
Everything would have been more difficult, says Jecita, without the support of the multi-professional team. "For me it's like they're my body, they give me what I can't. If it hadn't been for this work by the BLH, my son wouldn't be alive," she acknowledged.
At the maternity ward, Jecita got to know the work of the health professionals linked to the Brazilian Network of Human Milk Banks (rBLH), a strategic action by the Ministry of Health recognized worldwide for its contribution to reducing neonatal mortality and morbidity indicators and the incidence of chronic non-communicable diseases. In all, the network has 227 human milk banks (BLHs) that work far beyond collecting, processing and distributing milk to premature and low-birth-weight babies. These are breastfeeding support homes that have a lot of stories to tell in their soon to be 40 years in 2024.
The first BLH emerged in a context of early weaning and encouraging the use of artificial formulas, which were seen as superior to breast milk. Created in 1943, the BLH at the current National Institute of Women's, Child's and Adolescent's Health Fernandes Figueira (IFF), at Fiocruz, only dealt with special cases until 1984. This was a time when a new operational paradigm began to be implemented, which allowed milk banks to expand across the country and consolidated the first SUS network – and made the Federal District the only place in the world to achieve self-sufficiency in breast milk and the only state in the country to have legislation regulating this policy.
João Aprígio Guerra de Almeida was the driving force behind the whole process that culminated in the creation of this new paradigm for Human Milk Banks. Aprígio, a food engineer, told Radis that in the 1980s, infant mortality in the country was high and breastfeeding was already recognized as an effective way to mitigate and reduce the problem, which was decisive in strengthening the expansion of the Brazilian BLH model.
IFF/Fiocruz was the seed of the rBLH. Until the 1980s, there were only five units. Aprígio reveals that, at this time, the realization dawned that the milk bank could not be a human dairy. "What about the woman? Where was she in this process? Being able to bring women to the center of the human milk bank scene, to see them from a more understanding perspective, was another big difference," he noted, commenting that the paradigm shift has made women the protagonists of breastfeeding and babies the beneficiaries of the food.
According to Aprígio, the Brazilian model is based on the strong reference of breastfeeding and food technology, which increases the safety of what is done in the bank and the opportunity to use its functionalities as a therapeutic resource. "It's not just transferring the model, but transferring principles on the same basis of technical rigor and supporting each location while respecting its peculiarities," he told Radis. He is today the coordinator of the Ibero-American BLH Program and the Global Network of Human Milk Banks. In 2020, Aprígio was awarded the Dr. Lee Jong Wook Prize, awarded annually by the World Health Organization (WHO) to individuals or institutions that have contributed to major advances in public health.
In 1984, the BLH Technical Group formalized the beginning of the process of institutionalizing hitherto isolated experiences and, in 1987, it was signed the first agreement for IFF's BLH to become the National Reference Center. The banks were taken to the rest of Brazil.
Social cooperation was extended to other countries. Gradually, the local network became a global network. After the Brazilian municipalities, it crossed borders and is now present in countries in Latin America, the Caribbean, the Iberian Peninsula, Africa and the BRICS, a group comprising Russia, India, China and South Africa, as well as Brazil. The work of the BLH Network was recognized as having contributed the most to reducing infant mortality worldwide in the 1990s and the network was awarded the Sasakawa Health Prize in 2001.
Danielle Aparecida da Silva is the coordinator of the National Reference Center for Human Milk Banks (IFF/Fiocruz), responsible for strategic actions and for standardizing the procedures of the entire network. She told Radis that the Brazilian model differs from others in that it considers human milk to be a functional food, carrying out processing and quality control based on food technology and aiming to meet the specific needs of each recipient.
She also emphasized the importance of the rBLH developing actions in breastfeeding care, supporting lactating women. "Milk banks welcome women, answering all their questions and dealing with common problems during this period," she explained.
Danielle, a food engineer, emphasized that sharing knowledge was and continues to be the driving force behind the network's expansion. While before, to set up new units, managers and staff went to the municipalities for technical training, there is now an online training and certification system, developed by rBLH professionals.
Antonio Flávio Meirelles, director of the IFF, told Radis that the network is an example of local action that can be spread across the country and become an international network for strengthening breastfeeding. "It's a diplomatic action by our country to achieve the goals of the 2030 Agenda, the Sustainable Development Goals," he said.
Within the SDGs, breastfeeding is linked to good nutrition, food security and reduced inequalities and sets a target of 70% exclusive breastfeeding in the first six months. Mariane Curado, nutritionist and coordinator of the rBLH in the Federal District, points out that, with the structured work of the network, the rate in the Federal District is 51.1% exclusive breastfeeding. In Brazil, the country operates with an estimated deficit, in average terms, of around 45%.
Every state and the Federal District has at least one milk bank. Between 2000 and 2022, the number rose from 109 to 227, an increase of 108%. Most of them are installed in the Southeast, with 93 units, which corresponds to 36% of the total. The Northeast, with 53, accounts for almost 22%; the Central-West, with 27 units (18%); the South, with 38 (17%); and the North, with 16 (6%). There are also 234 collection points (PCL) integrated into the network.
In 22 years, the donation of 3 million women has resulted in 3.4 million liters collected and benefited 3.5 million newborns. Through the breastfeeding support rooms, 37 million women have been welcomed and advised. All the data is available on the rBLH website. In 2006, a system created in partnership with DataSUS computerized the entire process and began to aggregate various indicators by city and region.
The control of milk processing, which used to be manual, has also been computerized. "Everything was written down in what we affectionately called the 'big book'. Which milk arrived, which would be processed, the volume and its characteristics," Danielle recalled. Donors write the date and time of their first collection on the jar next to their name. "Every now and then, we get sweet notes," said Danielle, showing a jar that read "Donated with love".
One jar may not seem like much, but it is. For the rBLH, any volume matters. This is because one 200 ml jar of donated milk can feed up to 10 premature or underweight babies.
Technology development and innovation have marked the history of the Brazilian BLH Network. Franz Novak was the technical manager of the BLH Quality Control Laboratory and the National Reference Center for BLH. "We started from absolute zero," he said at the IFF's 80th anniversary seminar, held in Rio de Janeiro at the beginning of October. "The BLH unites two parts that must never be separated, as they complement each other in their activities. It is the BLH that practices, promotes and protects breastfeeding," he said.
Franz said he is proud of the many creative technological solutions that have driven the consolidation of politics. Among them, he highlighted the standardization of the pasteurization of Milked Human Milk (MHM) and quality control, with simple, inexpensive and effective methodologies, among many others that have been conceived by the team throughout the network's history.
In October 2023, a cooperation agreement was signed between the National Institute of Women's, Child's and Adolescent's Health Fernandes Figueira (IFF/Fiocruz) and the Cândido Tostes Dairy Institute (ILCT) to develop technologies that make the most of the nutritional potential of donated breast milk. Additionally, a specialization course in breastfeeding was launched for the SUS and the Network of Human Milk Banks of the Community of Portuguese Language Countries (rBLH - CPLP). In practice, Brazil transfers the principles of its technology and helps countries adapt them to the local reality, in an agenda that involves the Brazilian Cooperation Agency (ABC), the Ministry of Health and Fiocruz.
Human milk is not a commodity
Human milk is good for the mother's and baby's health and does not overburden the public health care system. The food is donated and collected free of charge. Miriam Santos, rBLH's Central-West coordinator and vice president of the National Milk Bank Commission, believes that donating breast milk is the first act of solidarity that women teach their children.
"If it becomes a commodity, as it is in some countries, how will this woman's child be fed? What existed in the previous model caused a great deal of anguish because, sometimes, women would stop breastfeeding to go to the bank to fill several jars and get a food basket in exchange," she recalled, referring to the BLH model which lasted from 1943 to 1984.
Pediatrician Marlene Roque Assumpção knows exactly what Miriam is talking about. As a resident, she saw the transformation from the old model designed to cater for special cases to an internationally recognized public policy. Marlene arrived at IFF's BLH in 1977. At the time, the units were compared to human dairies for creating a commercial relationship of buying and selling a food that had pharmacological properties.
"The milk was donated in exchange for life savings," she recalled at the seminar celebrating the 80th anniversary of IFF's BLH. Most of the donors were poor women who saw donating milk as a way of supporting themselves. Moreover, most of the donations went to external recipients.
Marlene said that the better-off women paid "something" for the milk donated and the money was used to buy layettes and food bags for the poorer mothers. "The bigger the collection, the bigger the reward, which sometimes led to fights and comments between donors. Some were accused of mixing water to increase the volume," the pediatrician told Radis.
The milk was distributed preferably as a raw product, not undergoing any kind of processing. "The most we did was put it in the fridge, it wasn't even a freezer," said the pediatrician. Today, human milk is pasteurized and frozen to avoid the risk of contamination, and distributed with certified quality.
In the change to this new BLH, milk is understood as a complete food. A "medicine food" and a "life food," as Marlene said. "There is no other gold standard food for babies," she noted. It is no coincidence that the month that symbolizes the campaign to encourage breastfeeding is the Golden August.
Awareness-raising for donations also takes place on May 19, in commemoration of National Human Milk Donation Day. "Besides its many properties, human milk is the only food that doesn't distinguish between class, ethnicity, religion or origin. It comes from a mother who donates, a mother who has surplus, a mother who wants to help other mothers and children. It's a universal milk," said the pediatrician.
For Cecy Dunshee de Abranches, an IFF doctor, child and adolescent psychiatrist and family therapist, breastfeeding is "affective feeding" and the first major postpartum relationship. With her daughter in the IFF nursery, the doctor said she breastfed and donated milk. "What was left over, I donated to the BLH," she recalled.
Greater contact between mother and baby is an ally in encouraging breastfeeding. During the pandemic, with mothers at home and freer to feed their babies on demand, there was a surplus of human milk donated to the rBLH.
All for breastfeeding
Simone Saldivia is a nutrition technician and works in breastfeeding advice and quality control at the BLH of the Hospital of Clinics of Porto Alegre. She told Radis that the BLH team works in the obstetric and pediatric inpatient areas, but the milk collected is preferably used by babies in the neonatal ICU. In 2022, 14,000 individual visits were made and around 13,000 donors fed more than 10,000 babies.
"When the mothers leave, it's plain to see the feeling of gratitude that they transfer to us for our work, for having been able to maintain lactation during the hospitalization period, which is a major challenge," she said. Simone revealed that many people are still unaware that the BLH is a breastfeeding support center and that it also provides free advice to mothers with healthy babies who have difficulty breastfeeding.
Graduated 20 years ago, nutritionist Juliana Neri Ferreira works at the BLH of the Sobradinho Regional Hospital (HRS), in the Federal District. She told Radis that "the universe opened up" when she joined BLH. "The BLH covers the areas of clinics, care, hygiene and food technology. There are several areas of nutrition in one place," she said.
Anyone who experiences women's stories of breastfeeding and the development of their children becomes a promoter of the practice, said Juliana. "We also need to empower women. It's a lot of work".
Working at HRS for ten years, nurse Josele Gonçalves regrets that there is still a culture against breastfeeding. "We row against the tide all the time. Besides the industry, which is very strong, there is advertising and the family's influence. People buy formula or a feeding bottle and think that's the right thing to do," she said.
For her, breastfeeding is not an isolated act and it is important to raise awareness among the puerperal woman's support network. "It's a joint effort: the donation is the result of all the work that goes into breastfeeding," she said, adding that she is proud to help mothers. "I see mothers who go in crying and come out smiling. It motivates us every day".
Every jar makes a difference
Isília Aparecida Silva, a professor in the Department of Mother-Child and Psychiatric Nursing at the School of Nursing at the University of São Paulo (USP), stressed that "women are practically alone with their milk production potential and need to be supported". According to the doctor, milk donation cannot be centered on the potential donor woman and needs to involve society as a whole.
Sônia Venâncio, coordinator of Child and Adolescent Health at the Ministry of Health, stressed the need to strengthen networking. "If we coordinate primary care with maternity hospitals and milk banks, we can maximize all this effort," she said.
Renara Guedes Araújo, technical advisor for breastfeeding actions at the Ministry of Health's Coordination of Child and Adolescent Health Care, said that the rBLH should be present in all parts of the country. "For us to achieve this, we need to make families aware of the importance of breastfeeding and donating human milk, so that those who breastfeed donate the surplus," she said.
She is the mother of four and the youngest, Mateus, was born at 37 weeks with transient respiratory distress. Renara had previously donated milk and thought that breastfeeding Matthew would be easy. It wasn't. "One day I had to remove 2 ml of milk and nothing came out," she told Radis. In the ICU, Mateus received milk from the BLH. Then, at home, he was exclusively breastfed and her mother became a donor. "I realized how much each ml makes a difference to the recovery of a hospitalized newborn," she recalled.