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This article was originally published by Quartz Africa here.

By Annabelle Timsit

Every morning at Pumwani Maternity Hospital in Nairobi, a group of new mothers files into a spacious room housing Kenya’s first human milk bank. The room, freshly-painted aqua blue and bustling with nurses, is lined on either side with private lactation booths separated by curtains speckled with hearts and stars. They’re there to donate their extra breast milk to the hospital’s premature babies in need.

That need is great: fifteen to twenty premature babies are born at Pumwani every day.

One of the leading causes of deaths of children under five is complications related to births that happen before 37 weeks of pregnancy. This is a global problem, but one that is unevenly distributed. More than 60% of premature births happen in Africa and South Asia. Of the 10 countries with the highest rates of preterm births, eight are in Africa. In Kenya, 13,300 kids under five die every year as a result.

One of the best ways to protect these newborns, and help them grow, is to give them their mothers’ milk within their first hour of life, and for at least six months afterwards. But this is not an option for up to 40% of preemies in neonatal intensive care units (NICUs) around the world whose mothers can’t breastfeed for health reasons. There is an effective, but not uncomplicated, way to help them: Human milk banks, which collect, store, and pasteurize donor milk.

Kenya is the third country in sub-Saharan Africa to establish a milk bank, following banks established in South Africa from 1980 and Cape Verde in 2011. It will serve as an important test case of whether human milk banks can navigate a difficult public health environment to effectively and sustainably reduce high rates of neonatal mortality.

“If it’s a success, we can use our narrative to scale up,” says Beth Maina, Pumwani’s deputy medical superintendent.

Human milk banks

The first hospital to formally freeze and distribute donor milk launched in Vienna in 1909. Today, there are more than 500 non-profit human milk banks operating in close to 40 countries, run by charities or hospitals (these differ from for-profit milk banking companies, which have increasingly cropped up in recent years and pose different challenges.)

Public health advocates of nonprofit human milk banks say they are cost-effective ways for hospitals to deal with some of the complications vulnerable babies face in their first few months of life, by helping to shorten hospital stays, avoid infections that are expensive to treat, and eliminate the high costs of purchasing baby formula.

While donor milk isn’t as good for babies as their own mothers’ milk, which is specifically tailored to her baby’s nutritional and immunological needs, it is an excellent nutrition source for babies, and can provide more benefits than formula. Donor milk has been shown to help protect babies against necrotizing enterocolitis (NEC), a medical condition that preemies are especially susceptible to, in which bacteria invade portions of the intestines and can destroy the wall of the bowel. It can also be better for babies’ central nervous system development.

Funded by international donors, nonprofits, and run by the Kenyan health ministry, the Pumwani Maternity Hospital Lactation Support Center and Human Milk Bank faces an abundance of challenges. Milk banks are expensive to set up and maintain. Donor milk carries contamination risks, and needs to be pasteurized to avoid the transmission of infection, a process that can reduce the bioactive components of human milk that are beneficial to preemies in the first place. Supplies of donor milk are also limited, and religious or cultural attitudes can sometimes prevent mothers from either donating or accepting human breast milk.

Strong institutional and community support for milk banks can help them succeed. About a decade ago, nonprofits and advocate groups convinced the South African Ministry of Health to invest in human milk banks as a way to promote exclusive breastfeeding and, ultimately, reduce the country’s neonatal deaths.

Together with local and national governments, the country wrote guidelines and standards to promote the use of hospital and community-based milk banks, resulting in a network of more than 40 today. They supply milk to thousands of babies every year.

Pumwani Milk Bank

Building off of South Africa’s success, and with the help of Kenya’s African Population and Health Research Center (APHRC) and PATH, the country’s Ministry of Health began polling women on their openness to donating breast milk a few years ago. It then decided to locate its first milk bank in Nairobi, which has the highest neonatal death rate in the country.

The team at Pumwani recruits donor mothers in the neonatal ward and antenatal clinics, connecting them with nutritionists and counselors who explain the process, which is unpaid and voluntary. Prospective mothers are screened for common infections, and their milk is screened for contamination before and after pasteurization. Cleared milk is dispatched to preterm babies who need it in the neonatal unit and postnatal ward. Pumwani has recruited 85 donor mothers since opening in March, and the nurses say they have already seen an impact on neonatal mortality rates.

It hasn’t all been smooth sailing. The milk bank relies on specialized pasteurizers and freezers manufactured in the US and UK. The machines didn’t arrive on time, delaying the bank’s launch. And the nurses worry that they could break down in case of power outages, which are common.

Pumwani has also had to deal with other challenges that illustrate how complex it can be to establish a milk bank, especially one that serves poor and vulnerable women. Deputy superintendent Maina and pediatric nurse Faith Njeru say teaching donor mothers how to care for themselves is one of their greatest challenges. “We have put it at the forefront [educating] the mothers on hygiene,” says Njeru, “not only because they are donating this milk, but also for the benefit of their own children.”

The biggest risk is contamination and infection. So far, Maina says the bank has only had one contaminated batch of pasteurized donor milk, which they immediately got rid of. But the risk is always there. Human milk banks have to put in place stringent quality assurances to prevent infection from spreading. Rafael Pérez-Escamilla, a professor of epidemiology and public health at the Yale School of Public Health, says keeping up these standards will be difficult if Kenya tries to scale its milk banks too quickly. “The worst-case scenario is when they are moving too fast and they start having transmissions of disease, because that’ll obliterate confidence in the whole process.”

The public healthcare system in Kenya is overextended, understaffed, and underfunded. Last November, a report in Kenya’s Daily Nation chronicled accusations of chronic mismanagement, a lack of funding, and poor conditions for mothers at Pumwani.

Kiersten Israel-Ballard, associate director for Maternal, Newborn and Child Health and Nutrition at the global health NGO PATH, says working with “massively under-supported, under-budgeted, under-staffed” hospitals is a necessary part of developing human bank networks in the countries that need them most. While “not every hospital should have a milk bank,” she says, “Pumwani was selected because of so many things they do right.”

What comes next?

To figure out how to make its first pilot milk bank a success, and leverage that model into a national network, Kenya can look to Brazil, which uses its network of 225 milk banks to promote breastfeeding and maternal and child health.

The country opened its first milk bank in 1943, and began to use them as part of a larger strategy to promote breastfeeding in 1985. Since then, its neonatal mortality rate has plummeted from 30.1 per 1,000 births to 8.5 in 2017. We don’t know how much of this progress is exclusively due to milk banks, but experts say they played a big part. These results led UNICEF to conclude that milk banks have “the highest return rate of any bank in the world.”

Advocates of milk banks believe the facilities should be part of a broader strategy to promote breastfeeding and support new mothers. Pérez-Escamilla believes Brazil’s embrace of a multi-pronged approach played a big part. For human milk banks to be “fully effective,” he says, “they really need to become very visible … centers of activity to protect, promote, and support breastfeeding for all babies.”

While countries like Brazil can serve as examples for the rest of the world to follow, every country is unique. And there are no global guidelines on how to run human milk banks yet. The WHO is working on developing them, a process that could take years. In the meantime, PATH released their own toolkit for establishing and integrating these types of centers. Israel-Ballard says the future global guidelines should strike a balance between quality assurance and access: “What you don’t want is that there are some kind of guidelines that are implemented that Kenya could never achieve,” she says.

The Pumwani Maternity Hospital human milk bank has a long road ahead. If it succeeds in its mission to bring clean, fortified human milk to premature babies and reduce neonatal mortalities, it could pave the way to establish milk banks in Kenya and across sub-Saharan Africa. Conversely, if it fails, it could make it more difficult to establish them. The stakes are high, says Israel-Ballard: “They know the world is watching.”

Abdi Latif Dahir contributed reporting to this story.

Read more from the series on Rewiring Childhood. This reporting is part of a series supported by a grant from the Bernard van Leer Foundation. The author’s views are not necessarily those of the Bernard van Leer Foundation.