Introduction
The concept of milk kinship establishment has been a
barrier for Muslims to donate and receive donor human
milk for many years. During the recent relaunch of the
Centre for Islam and Medicine (CIM), a lively roundtable
discussion moved the discussion forward to enable
solutions to be found to this delicate debate.
The benefits of human breast milk to infants are well
known, from protection against common childhood
illnesses to being less likely to develop obesity as they
get older. (1) For premature babies, receiving formula
milk can increase their risk of developing necrotising
enterocolitis, one of the leading causes of death in this
cohort of infants, as well as increase the risk of sepsis
and inflammation of the gut endothelium. (2) Donor
breast milk is used to protect babies when mothers are
still establishing their own milk supply or if infants do
not have access to their own mother’s milk. (3)
Infants have received donor milk for thousands of years.
When mothers were unable to breastfeed their infants,
they were given to wet nurses who breastfed them. (4)
Human milk banks, created in the twentieth century, help
to “screen and recruit donors, and have wide-ranging precautions to ensure the safety of donor milk,” including
testing for bacteria and heat treating the milk at 62.5
degrees for 30 minutes. It is estimated that more than
800,000 infants receive donor milk across the world each
year. (5)
Breastfeeding, with specific criteria, causes a milk
kinship in Islam between an infant and the women
breastfeeding him or her. This milk kinship, known as
‘rida’ or ‘rada’, prohibits marriage between the breastfed
individual and close relatives, such as the children, of the
donor. (6) This milk kinship, whether through wet nurses,
or through milk banks, can cause challenges when
breastfed infants grow and consider marriage. When
donor human milk is anonymised, further barriers are
created due to the real but extremely small chance of
marrying a milk relative, and this impacts on the clinical
use of donor milk in areas with predominantly Muslim
patients. (7)
Milk Banks and Milk Kinship in Islamic Law
A variety of opinions have been expressed regarding
milk banks by Islamic scholars. Shaykh Yusuf al
Qaradawi presented his responses to a question regarding
milk banks in 1983 at the Islamic Organisation of Medical Sciences (IOMS) and also at the International
Islamic Fiqh Academy (IIFA) in 1985. In 2004, his fatwa
was presented at the European Council for Fatwa and
Research (ECFR), which issued a ruling stating that there
should be no barrier in Islam to the establishment or use
of human milk banks.
Al-Qaradawi praised the donation of milk and the aims of
a milk bank to help protect the lives of premature infants.
His fatwa, religious edict, opining that there was no
barrier in Islam to milk banks was on the basis that this
type of donation and feeding of milk did not institute
kinship and therefore did not cause marriage prohibitions
in Islam. His opinion was based on 3 arguments:
- Based on the exact meaning of ‘rada’, establishing
kinship would involve suckling and being in close
contact with the donor mother, not just consumption
of her milk. As donor milk from milk banks involves
bottle feeding, Al-Qaradawi said this would not
cause kinship. - The anonymity of the woman or women donating
milk and the exact amounts of milk donated meant
that kinship could not be established. - In a situation of hardship, where the preservation of
life was a concern, a lenient approach was more
appropriate.
These opinions and arguments were challenged in 1983
and 1985, where the majority of scholars did not accept
the arguments, and also more recently in 2014 when
Mufti Zubair Butt was asked to provide a response on
behalf of the Muslim Council of Britain (MCB) to a
similar question posed regarding the Islamic perspective
on milk banks. (8,9)
- The opponents argued that ‘rada’ did not only mean
direct suckling and could be from a bottle, an opinion
held by the majority of Muslim jurists within the
well-known four Sunni schools. - The opponents accepted the second argument but did
challenge the idea of allowing this situation of
uncertainty to occur. In the Shafi’i and Hanbali
schools, milk kinship is only established after a
minimum of 5 satiating sessions of suckling. The
Hanafi school require only one suckling session,
irrespective of the amount suckled. There are also
differences of opinion regarding pooled milk and the
establishment of milk kinship; Imam Abu Yusuf
opined that kinship only occurs with the donor whose
milk is dominant. The preferred Hanafi and also the
Hanbali and Maliki opinions are that milk kinship
occurs with all donors to the pool. The Shafi’i school have additional conditions to decide if kinship is
established. With regards to anonymity, the Hanafi,
Shafi’i and Hanbali schools all agree that this does
not establish kinship, whereas the Maliki school take
a more cautious approach. - The opponents felt that there were obvious processes
that could be put in place to avoid requiring a more
lenient approach.
Milk Banks and Donation in the United Kingdom
The British Association of Perinatal Medicine
recommend that “donor human milk may be considered
in babies born at < 32 weeks gestations and/or < 1500
grams to establish enteral feeding when mother’s own
milk is unavailable or insufficient to meet their baby’s
requirements.” (10) UK human milk banks adhere to
NICE clinical guidelines, which require tracking and
tracing of donor milk with records being kept for a
standard of 30 years. The documented information
includes the donor and recipient identities. Donor milk is
not pooled in the UK and each donation is from a single
donor.
Milk Banks in Muslim Majority Countries
Human milk banks have been established in countries
such as Iran, Kuwait, and Malaysia. There are different
methods of ensuring that milk kinship is not a challenge,
from rulings that bottle feeding does not establish kinship
to both donors and recipients sharing identity and
information, and single donor and recipient agreements
making it easier to trace donations and milk relatives.
In Pakistan, the first milk bank for premature babies
suspended its service in June 2024, before donations had
begun, after a fatwa citing pre-conditions to establishing
the milk bank was withdrawn due to concerns regarding
milk kinship. (11)
Muslim Council of Britain Round Table Discussions 2015
In April 2015, the MCB hosted a round table discussion
involving scholars, paediatricians, and members of milk
bank organisations. The key resolution was that
“concerns about milk kinship should not lead to donor
human milk being withheld from vulnerable infants, as
there are safeguards in place that guarantee the
traceability of milk from donor to recipient.” (8)
Solutions were suggested to improve the traceability of donated milk so that if there was any concern that an
individual and their future spouse’s mother had received
and donated milk, then with the relevant consent
information could be shared to clarify whether the
mother’s milk had gone to this particular individual.
There was also an agreement that the team would
recommend extending the duration of the keeping of
donor milk records at the next review of the NICE
guidelines. This would be for longer than the current 30
years to ensure difficulties would not occur for
individuals wanting to marry after this period.
Contemporary Muslim Mothers and Infants and the Use of Milk Banks
The Centre for Islam and Medicine held an Islamic
Bioethics Seminar on April 25, 2024. During the event, a
discussion took place involving scholars, medics, and
specialist midwifery and milk bank colleagues. Case
studies were presented involving Muslim women whose
infants had either had or were recommended human
donor milk due to health issues.
The need for human donor milk usually comes at a very
emotional and sensitive time, after childbirth and when a
baby is often vulnerable and unwell. This is a period
where mothers are at significant risk of poor mental
health and the lack of adequate information, which is
sensitive to the needs of Muslim parents, and which
addresses the issue of milk kinship, can lead to struggles
with mental health and tensions between parents and
within families. The parents can feel guilty about whether
they are going against the teachings of Islam and one
parent even thought that it would be best for their child to
marry a spouse from a different country.
Parents often seek the counsel of scholars they trust
within their communities. Unfortunately, the advice they
are given can be conflicting and confusing. A lack of
awareness from healthcare professionals means parents
are not always signposted to specialist colleagues and
therefore feel a lack of support during this difficult and
emotional journey.
Muslim parents also have concerns regarding the
traceability process and worry that records are only kept
for 30 years. They are also concerned that the milk their
child receives will be from multiple sources.
The focus has been on infants who require breast milk for
medical reasons. There are also mothers who are unable
to provide their healthy infants with breast milk but are willing for them to receive donor human milk, and
improved information and guidance will help them too.
What Next?
We must all be clear, as concluded in the 2015 MCB
roundtable discussion that “concerns about milk kinship
should not lead to donor human milk being withheld
from vulnerable infants.” (8) Pragmatic and patient
centred outputs will help to ensure that the systems and
processes in place help reassure everyone involved, and
all parents in situations where donor human milk is
required will be provided with the necessary information
to make informed decisions.
When the NICE guidelines are updated, it is imperative
that the length of record keeping is increased. There must
be robust systems to ensure traceability of donated milk
so that donors and recipients are aware of who to contact
should they discover that a potential spouse may be a
milk relative. Should donors and recipients keep their
own records to help tighten the process?
Further discussion and debate are required of scholars to
come to an opinion regarding whether issues such as
donor anonymity can be used as a legitimate reason for
milk kinship to not be established, and therefore make
the use of milk banks more acceptable to Muslim parents
and families.
Education of healthcare professionals, scholars and
parents will allow for a better understanding of the need
for donor human milk, and allow the dissemination of
appropriate guidance to those who need it.
The consensus at the Islamic Bioethics Seminar was that
all colleagues wanted to work together to help improve
the current situation for Muslim mothers and infants
requiring donor human milk. Future expert meetings and
roundtable events can help to ensure that the ideas
suggested over the last few years can come to fruition
and improve the health of vulnerable infants who will
benefit greatly from this work.
References
- World Health Organisation. Breastfeeding. Available
at:
topics/breastfeeding#tab=tab_1.
2024. - Human Milk Foundation. Human Milk Foundation.
Available at: https://humanmilkfoundation.org/about
hmf/. Accessed June 20, 2024. - Barnett D. Donor Milk Bank. 2022; Available at:
https://rhc.nhsggc.org.uk/home/coming
glasgow/directory-of-services/donor-
Accessed Jun 20, 2024. - Ramli N, Ibrahim NR, Van Rostenberghe H. Human
milk banks – The benefits and issues in an Islamic
setting. Eastern Journal of Medicine 2010;15:163
167. - Shenker N. Maintaining safety and service provision
in human milk banking: a call to action in response to
the COVID-19 pandemic. Lancet Child Adolesc
Health 2020 July 1,;4(7):484-485. - Ghaly M. Milk Banks Through the Lens of Muslim
Scholars: One Text in Two Contexts. Bioethics
2012;26(3):117-127. - Tait F, Friel P, Powls A, Bowker G. Expressed breast
milk (maternal and donor). 2019; Available at:
https://www.clinicalguidelines.scot.nhs.uk/nhsggc
guidelines/nhsggc-guidelines/neonatology/expressed
breast-milk-maternal-and-donor/. Accessed Jun 20,
2024. - UKAMB. Resolution on the Use of Donor Human
Milk for Muslim Infants. 2016; Available at:
https://ukamb.org/resolution-on-the-use
human-milk-for-muslim-infants/. Accessed June 20,
2024. - Butt MZ. Islam and Milk Banks. 2014 January 14,.
- British Association of Perinatal Medicine. The Use
of Donor Human Milk in Neonates. BAPM 2023
April. - Sindh Institute of Child Health and Neonatology
Human Milk Bank is currently suspended and
referred to the Council of Islamic Ideology. 2024
June 21,.
