The Feasibility of Donor Human Milk Banking in Türkiye: A Qualitative Analysis of Religious,Institutional,and Policy Dynamics

Abstract

Research Aim(s)/Question(s):

The study aims to ascertain the views of relevant stakeholders regarding the facilitators and barriers to establishing human milk banks in Türkiye and to identify policy requirements for social acceptance.

Methods:

A qualitative approach was employed, using in-depth interviews with 22 experts in maternal and child health, including physicians, midwives, nurses, and health managers. Data were analyzed using Braun and Clarke’s six-phase thematic analysis framework.

Results:

Four central themes and twelve categories emerged: (1) the multifaceted value of human milk, (2) perceptions toward human milk donation, (3) social and institutional barriers, and (4) perspectives on current human milk feeding policies. Key findings highlight that while the biological importance of milk is universally recognized, donation is hindered by “milk kinship” concerns and legal ambiguities. However, the integration of donation data into the national e-Nabız electronic health record system and alignment with religious foundations (e.g., Surah Al-Baqarah, Verse 233) were identified as critical policy facilitators.

Conclusion:

Stakeholders emphasize that human milk banking is a viable model for Türkiye if implemented through a framework that resolves legal-religious contradictions. Success depends on extending maternity leaves to support breastfeeding rights and establishing a formal dialogue with religious authorities. These findings provide a strategic roadmap for policymakers to integrate human milk banking into public health policy as a sustainable and socially acceptable service.

Keywords

Breastfeeding human milk banking milk kinship qualitative research Türkiye

Introduction

The World Health Organization (WHO, 2023) recommends exclusive human milk feeding for the first six months, followed by continued human milk feeding for up to two years or beyond. While its benefits for infant growth, immune support, and the reduction of non-communicable diseases are well documented (Bosi et al., 2016; Mathias et al., 2023), global exclusive human milk feeding rates remained below 45% between 2014 and 2021 (Global Breastfeeding Collective, 2021). In Türkiye, although 98% of children are human milk fed at some point, the median duration of exclusive human milk feeding is remarkably low at 1.8 months (Hacettepe University Institute of Population Studies, 2018).

The economic and public health implications of low human milk feeding rates are significant, affecting healthcare costs and national productivity (Pokhrel et al., 2015; Rollins et al., 2023). To address these challenges, health systems have increasingly integrated WHO and UNICEF policies to support and sustain human milk feeding (Heidari et al., 2016). When maternal milk is unavailable, pasteurized donor human milk is established as the preferred alternative, particularly for medically fragile newborns (Mathias et al., 2023; WHO, 2020).

Human milk banking is the organized practice of collecting, screening, and distributing donated milk (Obeng et al., 2023). Historically, “wet nursing” served as an informal precursor to modern banking. In Muslim-majority countries like Türkiye, wet nursing is a long-standing tradition, typically involving familiar family members or friends (Varer Akpinar et al., 2022). However, formal human milk banking—introduced globally in 1989—faces unique challenges in these contexts.

Despite the existence of over 700 human milk banks worldwide, their distribution is uneven, with a heavy concentration in North America, Europe, and Brazil (Israel-Ballard et al., 2024). The establishment of a formal system in Türkiye has been stalled since 2011, primarily due to religious concerns regarding “milk kinship” and public backlash (Varer Akpinar et al., 2022; Ozdemir et al., 2015). The feasibility of transitioning from informal wet nursing to a formal system depends on the synergy between religious interpretation, technological trust, and institutional readiness. Evaluating these dynamics is essential to understand why past initiatives failed and how future policies can be sustained.

The successful implementation of donor human milk banking requires navigating complex sociocultural, religious, and health system dynamics. While international consensus supports its importance, local barriers—including safety concerns and lack of awareness—persist (Muyangana et al., 2024; Weaver et al., 2019). Through an integrated analytical lens, this research aims to examine stakeholders’ perspectives on the feasibility of donor human milk banking in Türkiye. It specifically investigates how sociocultural, religious, and policy-related factors collectively shape the possibility of a formal milk banking infrastructure.

Methodology

Study Design

This study utilized a qualitative descriptive design to explore stakeholders’ perspectives on the feasibility of donor human milk banking in Türkiye. Qualitative methods were chosen to obtain a deep understanding of the complex sociocultural and religious dynamics surrounding this issue. The study is reported in accordance with the Standards for Reporting Qualitative Research (SRQR) guidelines.

Participants and Sampling

In this study, a “stakeholder” was defined as a professional or expert whose role directly influences, is involved in, or is affected by the potential implementation of human milk banking policy in Türkiye. This conceptualization included three primary groups: (1) Decision-makers and administrators responsible for health policy and institutional governance, (2) Clinical implementers (e.g., nurses, midwives, and physicians) who manage infant nutrition and maternal care, and (3) Advocates from professional associations and NGOs who represent the professional standards and societal perspectives. This multi-sectoral approach ensured a holistic exploration of the feasibility of milk banking from various professional standpoints.

A purposive sampling strategy was employed to recruit key stakeholders with expertise in maternal and infant health, nutrition policy, and clinical practice. Participants were selected based on their direct involvement in maternal-child health policy, clinical practice, or relevant NGO leadership in Türkiye. To ensure a broad representation of the Turkish healthcare landscape, participants were recruited from diverse geographical locations, including major metropolitan hubs such as Ankara and Istanbul, as well as various provinces in Central and Eastern Anatolia. Participants included a diverse group of stakeholders, including nurses, midwives, general practitioners, obstetricians and gynecologists, academicians, and health administrators working in various institutions such as the Ministry of Health, public hospitals, and universities, as detailed in Table 1. Inclusion criteria required participants to have at least 5 years of experience in their respective fields. Data collection continued until thematic saturation was reached—the point at which no new themes or insights emerged from the interviews. A total of 24 potential stakeholders were invited to participate in the study. Of these, 22 experts agreed to be interviewed, while 2 individuals (one health administrator and one clinician) declined to participate due to intense workload and time constraints. No participants withdrew from the study after the interviews were conducted.

Table 1.

Descriptive Characteristics of the In-Depth Interviewees

Participant Code	Sex	Job	Educational Background	Professional experience (Years)	Place of Work	Position/ Job Description
P1	F	Nurse	Midwifery (V) Nursing (B) Health Management (M)	31	Association	Founder and Chairman
P2	F	Nurse	Nursing (B, M)	32	Ministry of Health	Department of Child and Adolescent Health
P3	F	Nurse	Nursing (B, M)	31	Ministry of Health	Ministry of Health, General Directorate of Public Hospitals, Health Service Department, Manager
P4	F	Midwife	Midwifery (B) Health Management (M)	17	Healthy Life Center	Breastfeeding Consultancy, Risky Pregnancy Follow-up
P5	F	Midwife	Midwifery (B, M)	15	Provincial Health Directorate	Child, Adolescent, Women and Reproductive Health Unit
P6	F	Midwife	Midwifery (V) Laboratory Veterinary Medicine (A) Health Management (B)	33	Training and Research Hospital	Lactation and Relaxation Clinic, Pregnant School, Family Planning (IUA), Baby Friendly Hospital Evaluator
P7	F	Nurse	Nursing (V) Health Management (B) Nursing (M)	24	Provincial Health Directorate	Health Services, Maternal and Infant Health Data, Data Tracking and Featured Services
P8	F	Midwife	Midwifery (B)	32	District Health Directorate	Pregnant School
P9	F	Midwife	Midwifery (B) Public Health Nursing (M)	18	University Hospital	Pregnant School
P10	F	Nurse	Nursing (B, M)	25	Provincial Health Directorate	Health Services Directorate, Vice President
P11	M	General Practitioner	Faculty of Medicine	5	Provincial Health Directorate	Public Hospital Services
P12	F	Nurse	Nursing (B, M)	30	Provincial Health Directorate	Child, Adolescent, Women and Reproductive Health Unit
P13	F	Midwife	Midwifery (B)	10	Provincial Health Directorate	Child, Adolescent, Women and Reproductive Health Unit
P14	M	General Practitioner	Faculty of Medicine	18	Provincial Health Directorate	Family Health Center
P15	M	Physician Obstetrician and Gynecologist	Faculty of Medicine Obstetrics and Gynecology	5	Public Hospital	Department of Gynecology and Obstetrics
P16	F	Midwife	Midwifery (B) Health Tourism (M)	11	Public Hospital	Pregnant School
P17	F	Nurse	Nursing (B, M)	20	Public Hospital	Outpatient Services
P18	F	Nurse	Nursing (A)	12	Public Hospital	Gynecology and Obstetrics Clinic
P19	F	Midwife	Midwifery (B)	34	Freelance, Retired	Childbirth Preparation Education, Breastfeeding Consultancy, Birth Support, Trainer
P20	F	Midwife	Midwifery (V) Nursing (B)	32	Freelance, Retired	Breastfeeding Consultancy
P21	F	Midwife	Midwifery (A)	37	Freelance, Retired	Birth Support, Breastfeeding Consultancy, Founding Member of Anatolian Midwives Association
P22	F	Academician	Nutrition and Dietetics (B, M, PhD)	10	University	Department of Nutrition and Dietetics

Note: M: Male, F: Female.

V: Vocational high school.

A: Associate’s degree.

B: Bachelor’s degree.

M: Master’s degree.

PhD: Doctorate.

NGO: Non-governmental organization.

Data Collection

Semi-structured interviews were conducted by the researchers between March 2025 and April 2025. To facilitate the inclusion of stakeholders from different geographical regions, interviews were conducted both face to face and via secure online video conferencing platforms. Interviews lasted an average of 30 to 60 minutes. Face-to-face interviews were held at the participants’ offices to ensure a comfortable environment, while online sessions provided a professional and accessible alternative for participants located in different provinces. A semi-structured interview guide consisting of nine open-ended questions was developed based on the existing literature and the study’s objectives. The guide was pilot-tested with two experts to ensure clarity and relevance. With the participants’ permission, interviews were audio-recorded and transcribed verbatim. Data saturation was determined when no new themes or sub-codes emerged from three consecutive interviews, ensuring that the diverse perspectives of the 22 stakeholders were sufficiently captured.

Data Analysis

The data were analyzed using thematic analysis, following the six-phase framework described by Braun and Clarke (2006). Two researchers independently coded the transcripts to ensure inter-rater reliability. Discrepancies in coding were resolved through consensus and discussion with a third researcher. Themes and categories were identified manually to maintain a close connection with the data. To enhance trustworthiness, member checking was performed by sharing summary findings with a subset of participants for validation. Direct quotations are used in the results section to support the findings, ensuring that the participants’ voices are represented authentically.

Ethical Considerations

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) of [Cankiri Karatekin University] (Protocol No: 29.01.2025/18). All participants provided written informed consent prior to the interviews. Participants were informed that their involvement was voluntary, that they could withdraw at any time without penalty, and that their data would be anonymized using alphanumeric codes (e.g., P1, P2) to ensure confidentiality. It was explicitly emphasized that the views expressed reflect personal expert insights and do not represent the official positions of their respective institutions. The authors declare no conflicts of interest regarding the research, authorship, or publication of this article.

The participants were categorized based on their professional roles and institutional affiliations to ensure that clinical, administrative, and advocacy perspectives were adequately represented. Table 1 provides a detailed overview of the expertise and years of experience of the interviewees, which serves as the primary basis for the credibility of the findings.

Results

A comprehensive analysis of the interview transcripts revealed that the most frequently recurring keywords were “human milk,” “donation,” “religion,” “awareness,” “health,” “immunity,” “safety,” “trust,” and “Islamic.” The analysis identified four main themes and twelve categories, as summarized in Table 2. The following sections provide a detailed exploration of these findings, with participants’ professional backgrounds identified to ensure methodological transparency.

Table 2.

Summary of Thematic Analysis Results

Themes	Categories	Codes	Participant Codes
Theme 1: Importance and Value of Human Milk	Biological and Immune Contributions	antibody, immunity, IQ/EQ, infant mortality	P1, P3, P5, P7, P9, P16
	Spiritual/Mystical Meaning	divine gift, sacred, motherhood duty, infant right	P1, P2, P6, P10, P12, P13, P18
	Economic and Environmental Impact	GNP contribution, healthcare costs, eco-damage	P1
Theme 2: Perceptions Toward Human Milk Donation	Positive Outlook (Solidarity)	life-saving, social solidarity, alternative for motherless infants	P2, P4, P8, P10, P14, P19
	Concerns and Hesitations	trust, commercialization, organ trafficking fear, anonymity	P5, P6, P9, P11, P17, P21
	The e-Nabız Solution (Conditional Acceptance)	supervision, tracking, legal assurance, infection monitoring	P2, P3, P8, P9, P12, P16, P22
Theme 3: Social and Institutional Barriers	Institutional and Infrastructure Deficiency	bank lack, legal ambiguity, clinic/counseling issues	P1, P3, P4, P7, P14, P18, P20
	Cultural and Religious Barriers	milk kinship, lineage concerns, passive resistance	P1, P5, P11, P17, P21
	Religious Alignment and Policy Facilitators	Diyanet cooperation, Verse 233, social adaptation	P2, P5
Theme 4: Perspectives on Current Feeding Policies	Legal and Regulatory Inconsistencies	maternity leave, policy contradictions, worker rights	P2, P5, P15
	Industry Influence	formula dominance, marketing at congresses, global finance	P1, P4, P11, P12
	Social Media and Public Perception	information pollution, anxiety, perceived inadequacy	P4, P11, P21

Theme 1: Importance and Value of Human Milk

Biological and Immune Contributions: “Babies introduced to human milk have higher intelligence quotients, better growth curves, and lower risks of obesity . . .” (P9, Midwife). “We know that human milk meets 100% of nutritional needs in the first six months . . . it is vital in reducing infant mortality” (P7, Health Manager/Nurse).

Spiritual/Mystical Meaning: “When we have a baby, milk is secreted according to their specific need . . . it is a substance we call vital, and the baby’s sucking is a right” (P13, Health Directorate Expert/Midwife). “Human milk is sacred, and it is also considered valuable due to being a country where Islam is widespread” (P2, Ministry Manager/Nurse).

Economic and Environmental Impact: Beyond its clinical and spiritual value, participants discussed the broader societal implications of human milk feeding. P1 (Nurse/Association Founder) emphasized the significant economic and environmental benefits, noting that investments in breastfeeding could yield substantial national returns: “Increased breastfeeding rates could contribute approximately $300,000 annually to the GNP by reducing healthcare expenditures and formula-related environmental damage.”

Theme 2: Perceptions Toward Human Milk Donation

Positive Outlook (Solidarity): “There should be such an alternative for special situations, such as babies who have lost their mothers or who do not have access to milk” (P10, Health Directorate Expert/Nurse). “Milk donation can save lives and support social solidarity” (P19, Consultant Midwife).

Concerns and Hesitations: “I fear that if the private sector gets involved, this could turn into a business, just like organ trafficking” (P6, Hospital Expert/Midwife). “Every mother’s human milk is specific to her own baby and should remain so. I am worried about it turning into a commercial market” (P9, Midwife).

The e-Nabız Solution (Conditional Acceptance): “The donor and recipient must be processed in e-Nabız; this ensures the ‘milk siblinghood’ bond is legally and religiously monitored for life” (P8, District Health Specialist/Midwife). “It’s logical when done under control . . . a system through e-Nabız where we can monitor the infection status is necessary” (P2, Ministry Manager/Nurse).

Theme 3: Social and Institutional Barriers

Institutional and Infrastructure Deficiency: “Lactation clinics often exist only on paper; personnel assigned there often lack specialized counseling skills” (P1, Nurse/Association Founder). “We don’t think our current infrastructure and our country have such a policy yet” (P4, Consultant Midwife).

Cultural and Religious Barriers: “A very serious passive resistance will arise before the cultural and religious resistance in society is broken” (P11, Physician/Health Director). “In the Izmir example, even after all tests were ready, it was rejected as a ‘project to corrupt the lineage’” (P1, Nurse/Association Founder).

Religious Alignment and Policy Facilitators: “If the Diyanet provides support, negative opinions can be broken . . . this issue needs to be discussed with religious authorities” (P5, Provincial Health Manager/Midwife). “Surah Al-Baqarah (2:233) recommends breastfeeding for two years; policies should leverage this religious foundation” (P2, Ministry Manager/Nurse).

Theme 4: Perspectives on Current Human Milk Feeding Policies

Legal and Regulatory Inconsistencies: “We advocate for six months of breastfeeding, yet maternity leave is only 16 weeks. This is a policy contradiction” (P5, Provincial Health Manager/Midwife). “Civil servants are only given 16 weeks; the mother cannot be with her child when needed most” (P15, Physician).

Industry Influence: “The formula industry’s economic power is a major barrier; even at professional congresses, their presence is overwhelming” (P12, Provincial Health Expert/Nurse). “Formula companies are at the top globally, which is a primary reason for low breastfeeding rates in Türkiye” (P1, Nurse/Association Founder).

Social Media and Public Perception: “Mothers experience intense anxiety about their milk supply, and social media has a big impact on this” (P4, Consultant Midwife). “There is disinformation on social media, but doctors can use these tools as a factor of trust to overcome obstacles” (P11, Physician/Health Director).

Discussion

The present study was a qualitative investigation aimed at ascertaining the views of relevant stakeholders on the feasibility of human milk banking in Türkiye. The findings are consistent with existing literature regarding the importance of human milk, while providing a deeper understanding of the unique social, religious, and institutional barriers in the Turkish context.

While participants’ consensus on the clinical value of human milk aligns with existing literature (Varer Akpinar et al., 2022; Zhang et al., 2024), our study extends this discourse by highlighting its macro-economic and ecological impact of human milk feeding, such as reduced national healthcare expenditures and decreased environmental damage from formula production, as supported by recent economic analyses (Hoang et al., 2024; Onah et al., 2025).

Regarding the perceptions of human milk donation, the “life-saving” potential of this practice was contrasted with deep-seated religious and hygienic concerns. Similar to findings in other Muslim-majority countries like Malaysia and Iran, religious reservations—specifically the concept of “milk kinship”—remain the primary factor contributing to negative attitudes (Doshmangir et al., 2025; Karacan et al., 2024; Ramachandran et al., 2024). A critical and unique finding of our study is the proposed use of the e-Nabız (national electronic health record) system to overcome these barriers. Participants suggested that if “milk siblinghood” could be legally and religiously monitored through a digital state infrastructure, the resistance rooted in “lineage protection” could be mitigated. In Türkiye, milk kinship is usually handled informally between people who know each other, so the “milk mother” is always known. However, formal milk banking creates a fear of “lineage confusion” because the donors are anonymous. Participants suggested that the e-Nabız system could solve this by providing the same “trust” and “certainty” that people find in traditional wet nursing.

The study also revealed significant perspectives on current human milk feeding policies. Participants highlighted a stark contradiction between public health recommendations and legal frameworks; while exclusive breastfeeding is advised for six months, maternity leave in Türkiye is limited to 16 weeks. This structural barrier, coupled with the overwhelming influence of the formula industry at professional medical congresses (Rusi et al., 2024), suggests that human milk banking should not be evaluated in isolation but as part of a broader reform in maternal-child health policies. Following Vilar-Compte et al. (2022), any legal or economic factor restricting a woman’s right to breastfeed should be recognized as a social injustice and a human rights violation.

Furthermore, the failure of previous attempts (e.g., the Izmir example) underscores that the establishment of human milk banks in Türkiye requires more than clinical readiness. It necessitates a “Religious Alignment” strategy. Our findings suggest that cooperation with the Directorate of Religious Affairs (Diyanet) and leveraging religious foundations, such as Surah Al-Baqarah (The Holy Quran, n.d.), are essential facilitators for social acceptance. The Diyanet’s role is also crucial. Participants noted that public trust depends on institutional “fatwas.” Therefore, religious authorities should not just approve the system, but also help design the digital tracking to make it culturally acceptable. While this study focuses on Türkiye, its findings offer a scalable model for other Muslim-majority countries and culturally diverse healthcare systems. The integration of national digital health records (e.g., e-Nabız) to resolve religious “milk kinship” concerns provides a technical solution that can be adapted globally to bridge the gap between traditional beliefs and modern clinical practices.

Implications for Policy and Practice

The findings of this study offer a roadmap for moving beyond the long-standing “stalled” status of human milk banking in Türkiye. To transition from theoretical feasibility to practical implementation, the following policy shifts are required:

Institutional Framework and Governance: Participants emphasized that a Turkish human milk banking model should be established as a state-controlled, non-profit system under the Ministry of Health to ensure institutional trust and prevent commercialization. In this model, donor milk would be sourced from healthy, screened mothers with excess supply, and prioritized for medically fragile newborns (NICU patients), orphans, or infants whose mothers have clinical contraindications to breastfeeding.

Digital Governance: The Ministry of Health should leverage the existing e-Nabız infrastructure to create a secure, encrypted registry for donor human milk. By providing lifelong digital assurance of “milk siblinghood,” the state can resolve the religious and legal concerns regarding lineage protection that led to the failure of previous initiatives.

Legislative Alignment: Policymakers must address the contradiction between clinical recommendations and labor laws. Extending paid maternity leave beyond 16 weeks is essential to creating an environment where breastfeeding and milk donation can realistically flourish.

Religious and Ethical Regulation: Establishing a formal collaboration with the Directorate of Religious Affairs (Diyanet) is necessary to provide institutional legitimacy to the milk banking model. Furthermore, stricter regulations on the formula industry’s influence in medical settings are needed to protect the neutrality of infant nutrition policies.

Limitations and Future Research

Although this study provides valuable insights into the feasibility of milk banking in Türkiye, it has certain limitations. First, the qualitative nature of the study and the purposive sampling of 22 stakeholders mean that the findings cannot be statistically generalized to the entire Turkish population. Second, while the study included policy-level and clinical experts, it did not directly involve formal religious scholars or the parents (potential donors and recipients) who are the ultimate end-users of such a system. Consequently, the religious perspectives discussed here represent the sociocultural perceptions and interpretations of healthcare stakeholders rather than established theological doctrine. Future research should prioritize large-scale quantitative studies to assess the attitudes of mothers and fathers toward donor milk. Furthermore, interdisciplinary research involving theologians and legal experts is recommended to develop a robust regulatory framework that addresses religious kinship concerns through technological solutions like e-Nabız. Such collaboration is essential to ensure that individual opinions are distinguished from formal spiritual authority in the development of national health policies.

Conclusion

In conclusion, while human milk banking in Türkiye faces unique sociocultural and religious hurdles, it is perceived as a viable model if supported by a robust policy framework. The feasibility of this system rests on a “triple-pillar” approach: legal assurance through legislative updates, digital transparency via the e-Nabız system, and religious alignment through formal institutional dialogue. By addressing these barriers collectively, Türkiye can establish a sustainable public policy that ensures equitable access to human milk as a fundamental health right for all infants.

Footnotes

Acknowledgements

The authors would like to thank all stakeholders who generously shared their time and insights for this study.

ORCID iD

Nazan Kartal

Ethical Considerations

The written consent was obtained and information about the study was provided to the participants prior to the data collection. The manuscript has been read and approved by all researchers. All authors have contributed to the study in accordance with the guides of the Council of Science Editors (CSE) and the International Committee of Medical Journal Editors (ICMJE). Ethical approval for the research was received from the Çankırı Karatekin University Ethics Board.

Author Contributions

Nazan Kartal: Methodology; Writing - original draft.

Gamze Arikan: Conceptualization; Writing - review & editing.

Ebru Yildirim: Investigation; Writing - review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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