An International Comparison Study into the implementation of the WHO Code and other breastfeeding initiatives

Germany

Germany - The WHO Code and Breastfeeding: An International Comparative Overview

Page last updated: 03 May 2012

Facts and figures

In Germany one of the main issues for the Government in terms of infants and family policy is the concern that more and more women remain childless. In 2008, according to the Federal Statistical Office (http://www.destatis.de) 21% of the 40 to 44-year-old women had no children; this was in contrast to 16% of women born 10 years earlier and 12% of women born between 1944 and 1948. Of the women between 35 and 39 years in 2008, 26% had no children. Childlessness among higher educated women is even more pronounced and has become so much of an issue that a special census was undertaken to ascertain the state of births and childlessness in Germany as national statistics have been wanting in this area. The most recent demographic data indicate that:
  • in 2009 there were 665,126 live births, equating to a TFR of 1.36, or 8.1 children per 1,000
  • the mean age of women in Germany expecting their first child was 28.5 years in 2008, compared with 27 years in 2001.
Data on breastfeeding rates are also lacking in Germany. Only sporadic data on breastfeeding have been available for the last 40 years (Kersting & Dulon 2002).The SuSe study conducted in 1997/98 is considered to be the first nationwide survey on breastfeeding and infant nutrition in Germany. It has also been one of the main sources of information regarding breastfeeding in Germany despite it being conducted more than 10 years ago. The findings were stratified into two groups: western mothers and eastern mothers. In the western group 88.7% of mothers starting breastfeeding at birth; this dropped to 60.5% exclusive breastfeeding at two months and 13.5% at six months. In comparison 97.1% of eastern mothers began breastfeeding, but by two and six months only 52% and 9.3% were exclusively breastfeeding.

In 2004, the Federal Institute for Risk Assessment launched a study in two Berlin clinics on the breastfeeding behaviour of women after giving birth. Little is published from this study; however it is stated that similar results were found in the Bavarian Breastfeeding Study which was undertaken by the Bavarian Regional Office for Health and Food Safety in 2005 (Kohlhuber et al 2008). Data from the Bavarian cohort study indicated that:
  • around 90% of infants are breastfed in Germany during the first days after they are born.
  • the breastfeeding rate (any breastfeeding) dropped to 70% after only two months and to 60% after four months.
  • only about 45% and 40% of infants were exclusively breastfed at the age of two and four months respectively.
  • at six months around 20% of mothers were exclusively breastfeeding compared to 51% of any breastfeeding.
From the 2005 survey, factors found to affect initiation include:
  • Education: Mothers with a higher education level were more likely to breastfeed.
  • Age of the mother: It was found that the younger the mother was when she gave birth the less likely she was to initiate breastfeeding, or to have breastfed in public.
  • Previous experience: mothers who had previously breastfed were more likely to breastfeed subsequent children.

Implementation of WHO Code

In Germany, the interpretation and implementation of the WHO Code is through law rather than selfregulation. The Code was first given legal effect in the Germany in 1994 with the transposing of the 1991 Directive 91/321/EEC into German law: Gesetz über die Werbung für Säuglingsanfangsnahrung und Folgenahrung (SNWG). The EU directive outlines the compositional and labelling requirements for infant formulas and follow-on formulas intended for use by infants (defined as under 12 months of age). It also outlines restrictions on advertising and the provision of information on infant and young child feeding to pregnant women and mothers of infants and young children. With the subsequent EU Directive 2006/141/EC on infant formulas and follow-on formulas, this legislation was recast into the Diaetverordnung (Verordnung über diaetetische Lebensmittel / Ordinance on dietary foodstuffs). This Regulation does not have the same legal standing as the original 1994 law. The Ordinance on dietary foodstuffs regulation also only details labelling and compositional requirements. Monitoring of the Diaetverordnung falls under the responsibility of the individual “states” (Laender) so that each of the 16 states has its own process and mechanism of handling complaints and violations.

Table 18: Implementation of the WHO Code in Germany
Article of the WHO Code Implemented Partially implemented/Not implemented
Article 2: Scope Regulations refer to compositional and labelling requirements for infant formulae and follow-on formulae intended for use by infants (defined as less than 12 months of age). The Regulations have a very limited scope and apply only to infant formula and follow-on formula rather than the whole range products covered by the International Code (including all breast milk substitutes, bottle-fed complementary foods, baby teas, bottles and teats etc).
Restrictions on advertising and the provision of information on infant and young child feeding to pregnant women and mothers of infants and young children are not discussed.
Article 4: Information & Education Not implemented in regulations
Article 5: General public & mothers Not implemented in regulations
Article 6: Health care systems Not implemented in regulations
Article 7: Health workers Not implemented in regulations
Article 8: Persons employed by manufacturers and distributors Not implemented in regulations
Article 9: Labelling Section 22 closely mirrors article 9. Regulations only apply to infant formula and follow-on formula rather than the whole range products covered by the International Code (including all breast milk substitutes, bottle-fed complementary foods, baby teas, bottles and teats etc).
Article 10: Quality Section 14 Composition regulations include strict limits on pesticide residues.
Article 11: Implementation & Monitoring Formal monitoring of all aspects not covered in regulations.


Complementary policies

Implementation of the Baby Friendly Hospital Initiative (BFHI)

It is unclear when the BFHI commenced in Germany; however data collected for the WHO Collaborating Centre for Maternal and Child Health in 2003 (EU Project on Promotion of Breastfeeding in Europe 2003) indicate that there were18 BFH out of a possible 1,100 maternity hospital units, with only 3% of births occurring in a BFH. A subsequent article published in German in 2010 (Haager-Burkert et al 2010) states that in 2009 only 37 certified clinical with maternity units were registered, corresponding to around 4% of all German maternity facilities. The study looked at the perceived difficulties for clinical staff and maternity units in obtaining Baby Friendly certification. Both the certified clinics and those preparing for BFHI certification perceived step 6 (exclusive breastfeeding) and step 9 (no use of artificial teats or pacifiers to breastfeeding infants) of the “10 steps to successful breastfeeding” to be the biggest obstacles. A lack of knowledge and acceptance of breastfeeding by mothers and staff also played a role. In 2011 there are 65 BFHI in Germany according to the German BFHI website http://eltern.babyfreundlich.org/willkommen.html

National Committee on Breastfeeding

As per the Innocenti Declaration, a Breastfeeding Committee was set up in 1994. It currently sits within the Federal Institute for Risk Assessment (BfR). The Institute was set up in November 2002 and is responsible for the preparation of expert reports and opinions on food safety. The aims of the Committee are to advise the federal government on initiatives to increase breastfeeding and provide practical recommendations on breastfeeding issues for doctors, midwives, hospital staff and mothers. Such recommendations include the following which corresponds to the 2008 WHA resolution (61.20):

”Infant formula can replace breast milk from birth onwards and like breast milk is suitable as the sole source of food for the first four to six months. After that infant formula plus weaning food can be given throughout the first year of life. Follow-on formula can replace breast milk at the earliest from the fifth month onwards. It is not suitable from birth onwards as it is not adapted to the needs of the very young infant. There is no compelling reason to switch from infant formula to follow-on formula. Weaning food is the name for all dietary foods intended specifically for infants (and small children) which should supplement the diet with breast milk or breast substitute products at the earliest from the 5th month and at the latest from the 7th month onwards.”

Top of page

Workplace

Of the approximately 38 million people aged 15–64 in paid employment in Germany, women have a participation rate of 66% compared to 76% for men. Women are more likely to work part-time than men, 45% compared to 9% (Massarelli & Wozowczyk 2010). The rate of women working part-time in Germany is higher than for most other EU countries. It has been suggested that this is because of the structural difficulty for women to combine labour force participation and childrearing (Fagnani 2007). While German policy has always promoted the notion of family; it has been the traditional family model of the stay at home mother and the male breadwinner (see Table 19). This model is reflected in the German taxation law and the lack of childcare facilities for women returning to work is also indicative of this view.

Table 19: Employment patterns in households of couples with children under six
Employment pattern %
Man full-time, women full-time 15.7
Man full-time, women part-time 23.1
Man full-time woman not working 52.3
Neither man not woman working 8.9
Total 100


The Government has recognised this as a barrier and a possible cause of declining birth rates and has recently begun implementing a range of changes to childcare policy and parental leave and benefits. Under the German Maternity Protection Act women are entitled to 14 weeks paid leave. This includes six weeks to be taken before the birth (unless the female employee explicitly declares they are able to perform work) and up to eight weeks after a normal birth – 12 weeks if the baby is born prematurely. Upon return to work women are entitled to breastfeeding breaks, without loss of salary.

In 2006 the Germany parliament passed the Federal Parental Benefit and Parental Leave Act (Parental allowance "Erziehungsgeld”). This law remodelled the existing paid parental leave system to be more akin to Scandinavian systems in the hope that it might increase the fertility rate. The parental allowance is paid to fathers and mothers for a maximum of 14 months, and can be divided freely between them but each partner must take at least two months. Under the new system, a mother or a father gets 67% of their net income (based on the last 12 months before the birth) however those with a very high income are considered illegible. The maximum payable is €1,800 and the parent requesting the paid parental leave must not work more than 30 hours a week after the birth. If there is no reduction of working time then only €300 can be granted which is the same amount for those who have not worked before the birth.

Under the Federal Parental Benefit and Parental Leave Act, parents are also allowed to take unpaid leave for the care and upbringing of a chid until the age of three years (Parental leave “Elternzeit"). This can be taken as either shared leave (both parents take time off) or as part-time leave. A proportion of parental leave (up to 12 months) is also able to be transferred to the period between the third and eighth birthday of the child, for example, during the first school year or for parents with more than one child.

In summary:
  • Women are entitled to 14 weeks paid leave: 6 weeks before the estimated birth and 8 weeks after birth.
  • Under section 7 of the Maternity Protection Act breastfeeding mothers are entitled to take time of off work to breastfeed/express milk (2 breaks of 30 minutes or one 60-minute break).
  • Employers may also be required to provide a suitable area to facilitate breastfeeding.
  • The Maternity Protection Act also prohibits discrimination and unfair dismissal during pregnancy and up until four months after giving birth.
  • Both parents are also entitled to receive a parental allowance for up to 14 months.
  • The Federal Parental Benefit and Parental Leave Act grants unpaid leave for up to three years and allows the employee to return to work after three years with the same conditions.

Childcare arrangements for babies under one year of age

Since 1996, parents are legally entitled to childcare for half a day for children ages 3 to 6 in a public day care centre. This entitlement means that children will receive at least three hours outside the home, which may facilitate part-time work, but does not allow for full-time employment of the main care-giving parent (Honekamp 2008). The situation for children under age three is less advanced; nationwide there is space in childcare for only 22.1% of all children under the age of three. In 2007 the German Government announced that the number of childcare spaces for children under the age of three was to triple by the year 2013, so as to provide spaces for 35% of all children in that age group. A recent UNICEF (2008) report highlighted that only 10% of children 0–3 years were enrolled in childcare, well below the OCED average of 25%. As a result many women, if they choose to return to work, would need to rely on family or friends for childcare. For these families a cash payment of €150 per month is available to support their at-home care-giving efforts. However, as of the beginning of August 2013, parents will be able to claim a legal right for a childcare space for their child under age three (the same already exists for children ages three to six).


Culture

Until recently, the male breadwinner model, with the wife devoted entirely to housework and child-rearing, permeated all family policy in Germany (Fagnani 2007). As such the majority of Germans considered that the best environment for children was at home with their mother. Little has been published around attitudes towards breastfeeding in Germany. What has been published is in agreement with other findings from studies elsewhere that socio-economic status, age and education have an influence on breastfeeding rates (Dulon et al 2001).

Interestingly the concept of “family” is very much promoted in Germany. In 2001 Germany spent €180 billion on family policy which amounted to 9% of the gross domestic product (GDP). About one-third of that sum was spent on family-related tax policies and two-thirds on income transfers to families. This means that in Germany the Government pays around 46% of the cost of children for their families. Despite these measures, birth rates have remained low and many mothers perceive childrearing as a burden and that work and family are incompatible (Honekamp 2008). The Government has tried to change this attitude with a range of measures that seek to assist families with work/life balance; however, it is yet to be seen whether this will translate into a higher birth rate.


Health system and health worker training

Germany has a universal health system. By law residents are required to have health insurance and this can either be under a public or private system. Public “statutory” health insurance is run by non-profit organisations, with premiums based on salary and employees and employers contributing about half each. The statutory funds are also funded in part by taxes to support the coverage of people who have never been employed or paid into the system. Some people can opt out of the public statutory funds and be covered by private “for-profit” insurance companies. Only about 10% of the German population (about 8.5 million people) is covered by private insurance.

As mentioned previously, Germany has a number of accredited BFHs and so health professionals would have access to the training associated with this initiative. However very little is documented about the training of health professionals in Germany in regards to breastfeeding. From the 2008 revised European Blueprint For Action (EU Project on Promotion of Breastfeeding in Europe 2008) it is noted that most EU countries do not have breastfeeding healthcare policies that meet current best practice standards as set out in the Global Strategy on Infant and Young Child Feeding. The use of quality-assessed courses for breastfeeding training is also low. The breastfeeding courses for pre- and in-service that do exist need to have their effectiveness evaluated and their content revised or revamped as necessary. It is probably reasonable to assume that these statements are representative of the German healthcare system given that Germany was not one of the countries that had followed the recommendations of the first Blueprint for action.


Summary

Compared to other EU countries, initial breastfeeding rates in Germany appear to be quite high. Good quality data however are lacking. There is no formal or systematic data collection for infant feeding in Germany and so what is available may not be an accurate reflection of breastfeeding behaviour.

Implementation of the WHO Code was initially given legal effect in Germany in 1994 with the transposing of the 1991 EU Directive 91/321/EEC into German law. This law was narrower in scope than the WHO Code and has since been amalgamated into Regulations concerning dietary foods. The main breastfeeding initiative in Germany appears to be the BFHI. A National Committee on Breastfeeding is in place but it is unclear how active the Committee is in terms of breastfeeding.

Germany appears to be going through a period of change in terms of family policies given the declining fertility rate. This has seen a significant shift in terms of child care services and parental leave entitlements. However It may be some years before these policies have an impact on national demographics and perhaps when they do breastfeeding will come more to the forefront in German health and family policy.
Top of page