frequencies and demographic determinants of breastfeeding and dha supplementation in a nationwide...

ORIGINAL CONTRIBUTION

Frequencies and demographic determinants of breastfeedingand DHA supplementation in a nationwide sample of mothersin Germany

Lars Libuda • Madlen Stimming • Christina Mesch •

Petra Warschburger • Hermann Kalhoff •

Berthold Viktor Koletzko • Mathilde Kersting

Received: 3 September 2013 / Accepted: 20 November 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract

Purpose German guidelines recommend breast milk as

ideal for infant’s nutrition, supporting exclusive breast-

feeding for at least 4 months. Moreover, in mothers with

insufficient fish intake, DHA status may be improved by

supplementation during pregnancy and lactation. However,

little is known on current rates of breastfeeding and DHA

supplementation in Germany. The objective of this study

was to analyse frequencies and demographic determinants

of breastfeeding and DHA supplementation in Germany.

Methods Data derived from a nationwide consumer sur-

vey of 986 mothers with children between 5 and 36 months

of age in Germany.

Results 78.3 % reported that they ever breastfed their

children, and 55.6 % of the mothers exclusively breastfed

for at least 4 months. Mothers who did not breastfeed were

less likely to be informed by their paediatrician or midwife

and were more often not informed at all; 27.8 % of mothers

used DHA supplements during pregnancy, 16.8 % post-

natal. DHA supplementation was more common in women

with a high versus a low fish intake. The social status was

the major determinant of breastfeeding initiation and

exclusivity and also DHA supplementation.

Conclusion Breastfeeding initiation and duration of

exclusive breastfeeding in Germany need to be improved.

Professional counselling and support, with a focus on

mothers from lower social classes, appears necessary to

increase current rates of breastfeeding initiation, duration,

and exclusiveness, but also to ensure a sufficient supply

with DHA in pregnant and lactating women, particularly in

women with low fish consumption.

Keywords Breastfeeding � Initiation �Exclusiveness � DHA supplements � Determinants

Introduction

German dietary guidelines recommend exclusive breast-

feeding as gold standard for infants’ nutrition for at least

4 months and continuation of breastfeeding thereafter for

as long as desired by infant and mother [1]. In Germany, a

national breastfeeding committee was established in 1994

and public health initiatives such as the UNICEF certifi-

cation of ‘‘Baby Friendly Hospitals’’ were set up—as in

many countries—in order to promote breastfeeding.

Overall, 73 hospitals out of a total of more than 1,000

maternity hospitals in Germany were certified as ‘‘Baby

Friendly Hospitals’’ up to January 2013, most of them

(n = 55) after the year 2005 [2].

The latest nationwide information on breastfeeding in

Germany deriving from the German Health Interview and

Examination Survey for Children and Adolescents (KIGGS)

in 2003/2006 point to a positive development in retrospec-

tively assessed breastfeeding rates [3]. Breastfeeding

L. Libuda (&) � M. Stimming � C. Mesch � M. Kersting

Research Institute of Child Nutrition (FKE) Dortmund,

Rheinische Friedrich-Wilhelms-University Bonn, Heinstueck 11,

44225 Dortmund, Germany

e-mail: [email protected]

P. Warschburger

Department of Psychology, University of Potsdam, Potsdam,

Germany

H. Kalhoff

Pediatric Clinic Dortmund, Dortmund, Germany

B. V. Koletzko

Dr. von Hauner Children’s Hospital, University of Munich

Medical Centre, Munich, Germany

123

Eur J Nutr

DOI 10.1007/s00394-013-0633-4

initiation increased from 74 % in 1986 to 81.5 % in 2005. In

contrast, the duration of any breastfeeding increased only

until 2001, but decreased afterwards [3]. The KIGGS study

did not provide rates of exclusive breastfeeding at the age of

4 months in 2005. Considering the complete study period

(1986–2005), 22.4 % of the mothers predominantly breast-

fed their infants at the age of 6 months [3]. The previous

nationwide SuSe Study in 1997/1998 revealed that only

33 % of all children were exclusively breastfed at the age of

4 months and 10 % at the age of 6 months [4].

Reviewing data on country-specific breastfeeding prac-

tices in Europe between 1998 and 2002, Cattaneo et al. [5]

observed a wide range of initiation rates between 63 and

99 %. Rates of exclusive breastfeeding seemed to decrease

rapidly with children0s age in all European countries and

varied between 1 and 46 % at the age of 6 months [5].

Although data from 2003 to 2007 point to slight improve-

ments [6], the rates of exclusive breastfeeding at the age of

6 months were still lower than recommended throughout

Europe. In Germany, data from the KIGGS study also

indicated slight increases in breastfeeding rates in Germany

between 1986 and 2005 [3]. As potential effects of breast-

feeding promotion might have occurred since 2005, current

breastfeeding rates are of public interest.

The identification of target groups for future breast-

feeding promotion might be a feasible way to increase its

effectiveness. In this context, breastfeeding initiation in

Germany was observed to vary with maternal age, resi-

dence (East vs. West Germany), and social status [3]. The

relatively high rates of 90 % breastfeeding in a regional

prospective cohort study in Bavaria in 2005 might confirm

regional differences in breastfeeding initiation [7]. How-

ever, as the impact of these determinants may have chan-

ged over time, demographic differences in breastfeeding

rates need to be re-examined.

One discussed beneficial aspect of breastfeeding is a

potential improvement of infants0 cognitive development

[8–10]. One factor which might mediate this potential

effect is the intake of long-chain polyunsaturated fatty

acids (LC-PUFA) and especially docosahexaenoic acid

(DHA). The DHA content in breast milk varies widely [11]

and depends primarily on maternal intake of preformed

DHA [11, 12]. Since the mean intake of fish as a DHA-rich

food is generally low in Germany [13], one might suppose

that DHA supplements could be an additional approach to

realise an adequate supply during pregnancy and lactation,

although there is currently no clear scientific evidence for

or against the usage of LC-PUFA supplements in preg-

nancy [14]. Furthermore, little is currently known about

DHA supplementation habits in Germany.

Therefore, the major objective of this study was to use

data from a nationwide consumer survey (1) to evaluate the

prevalence and the demographic determinants of

breastfeeding initiation and continuation (given as rates of

exclusive breastfeeding at the age of 4 months) and (2)

frequencies and determinants of DHA supplement usage

during pregnancy and postpartum in a large sample of

mothers in Germany.

Methods

Study design

The present survey was nested in the randomised con-

trolled trial PINGU (polyunsaturated fatty acids in child

nutrition—a German multimodal optimisation study). Pri-

mary objective of PINGU (study period: 2010–2013; study

location: Dortmund) was to examine the effect of two

approaches of dietary n-3 PUFA supply via complementary

food on endogenous DHA status and functional develop-

ment in the second 6 months of life: (a) commercial veg-

etable-potato-meat jars with n-3 alpha-linolenic-rich

rapeseed oil as a precursor of endogenous DHA synthesis

(intervention group 1) or (b) preformed DHA-rich fish

meals twice a week (intervention group 2). The control

group received commercial jars with n-6 linoleic-acid-rich

corn oil. The PINGU study was partially double blinded,

i.e., in the corn oil and rapeseed oil group, the affiliation

was blinded to subjects, outcome assessors, and investi-

gators. Only subjects in the fish group knew their assign-

ment as vegetable-potato-fish jars can be identified

olfactorically. However, outcome assessors and investiga-

tors remained blinded. Further details of the PINGU study

design were described elsewhere [15].

As part of the PINGU project, the present study was

designed to get an overall insight into consumer habits and

attitudes towards n-3 PUFA in young families in Germany.

A particular objective of this data analysis was to examine

the intake and its determining factors of foods rich in n-3

fatty acids in infancy, i.e., breast milk, fish, and rapeseed

oil. Data were derived from an existing access panel which

is regularly contacted to participate in consumer surveys

(Kantar Health GmbH, Munich, Germany). Thereof, all

mothers with children between 5 and 36 months of age

were selected for an online survey focussing on mother’s

and children’s dietary behaviour (field period from 26th

November until 16th December 2010). In total, 1,804

mothers fulfilled these inclusion criteria and were invited

online to participate. All potential participants were

reminded up to three times with a focus on mothers from

lower social classes. In order to avoid over-representa-

tiveness of younger children and to enable analyses of

potential time trends, an equal distribution of children’s

age strata (i.e., 5–12, 13–24 and 25–36 months) was

intended. Overall 1.013 out of 1.804 available mothers

Eur J Nutr

123

finally participated in the survey (56 % response rate). Of

those, 28 had to be excluded, because children were

younger than 5 months or answers were implausible or

conflicting (e.g., child’s current age lower than age of the

beginning of complementary feeding), resulting in a final

sample of 985 mothers who were considered for data

analysis.

In mothers with more than one child between 5 and

36 months of age, questions aimed on the youngest child.

Data were weighed for federal state, mother’s age at the

time of the survey, maternal level of school education,

maternal level of professional education, household

income, number of persons in the household, and com-

munity size according to the distribution of these variables

in German mothers.

Outcome variables and potential determinants

The online survey consisted of 48 questions within 5 dif-

ferent topics: (a) dietary behaviour of mother and infant,

(b) sociodemographic data, (c) information sources

regarding healthy child nutrition, (d) maternal attitudes

according to rapeseed oil and fish as a part of comple-

mentary food, (e) and nutritional knowledge with respect to

n-3 PUFA. Of those, we used the answers from the topic

(a) to define the following outcome variables: breastfeeding

initiation, exclusive breastfeeding for at least the first

4 months (only breast milk without other liquids, including

water or solids), usage of DHA supplements during preg-

nancy, and usage of DHA supplements postpartum.

Answers to topic (b) were used to define the following

potential determinants of breastfeeding: quartiles of

mother’s age at the time of the survey (Q1: B29 years,

Q2: C30 to B32 years, Q3: C33 to B36 years,

Q4: C37 years), number of children (firstborn vs. not

firstborn), residence in West or East Germany, residence in

north or south Germany, community size (small: B2,000

citizens, medium: 2,001–100,000 citizens, large: [100,000

citizens), and social class (low, medium and high). The

social classes were defined according to information on

maternal level of school education, maternal level of pro-

fessional education, and household income. Data on infor-

mation sources regarding child nutrition were used to

analyse whether mothers who initiated breastfeeding used

other information sources than non-breastfeeding mothers.

Statistical analysis

All statistical tests were performed using SAS� procedures

(version 9.2, Statistical Analysis Systems, Cary, NC,

USA). p values \ 0.05 were considered significant.

The frequencies of breastfeeding initiation, exclusive

breastfeeding at the age of 4 months, and DHA supplement

usage during pregnancy and postpartum were calculated

using the procedure FREQ that was also used to perform the

v2 tests and Mantel–Haenszel chi-square test for the uni-

factorial data analysis of potential determinants. Further-

more, logistic models (PROC Logistic) were used for

multifactorial analyses of potential determinants of breast-

feeding and DHA supplementation. For breastfeeding ini-

tiation and exclusive breastfeeding at the age of 4 months,

we examined 2 models: Model 1 included mother’s age

quartiles, number of children, residence in West or East

Germany, residence in north or south Germany, and social

class as independent variables. Model 2 additionally

included the variable community size as this information

was not available for all participants (not recorded by 51

subjects). For the analysis of DHA supplementation, a third

model additionally included breastfeeding initiation and

maternal fish consumption as additional independent vari-

ables representing maternal dietary behaviour.

Results

Frequencies and determinants of breastfeeding

About 78.3 % of the mothers reported that they ever

breastfed their infants or were still breastfeeding at the time

of the survey (Fig. 1a); 55.6 % of the mothers met the

recommendations to exclusively breastfeed for at least

4 months (Fig. 1b). Thus, 29.0 % of those mothers who

started breastfeeding did not achieve the minimum rec-

ommended duration.

Unifactorial analyses revealed regional differences in

breastfeeding initiation that was more common in East

Germany in comparison with West Germany and also in

north Germany in comparison to south Germany (Fig. 1a).

Overall, there was no linear association between mother’s

age and breastfeeding initiation. However, data point to an

inverse U-shape over quartiles of age resulting in a trend

for general differences between age classes (v2 p = 0.06).

Further predictors of breastfeeding initiation in the uni-

factoral analysis were the number of children and the social

status. The latter showed the highest differences between

the lowest versus the highest level of all determinants (66.0

vs. 85.7 % breastfeeding initiation).

Multifactorial analysis confirmed regional differences in

breastfeeding initiation between East and West Germany

(Table 1). Further predictors were mother’s social status

and the number of children. Differences between north and

south Germany were attenuated after including East/West

Germany (data not shown) and were no longer significant

in the fully adjusted model. Also mother’s age did not

predict the initiation of breastfeeding after inclusion of the

social status.

Eur J Nutr

123

Unifactorial analyses revealed higher rates of exclusive

breastfeeding at the age of 4 months in those mothers

living in small in comparison with large communities and a

positive linear association with maternal age (Fig. 1b).

However, data indicated slightly decreasing rates in the

oldest age group. As in case of breastfeeding initiation,

rates of exclusive breastfeeding significantly increased

with social class, whereas differences between the lowest

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Maternal age

Rat

es o

f br

east

feed

ing

initi

atio

n [

% o

f al

l mot

hers

]

Residence size* Social classNumber of childrenPart of Germany

p=0.0008a p=0.0002a p=0.083b p=0.278b p=0.0012a p=0.0001b

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

Maternal age

Rat

es o

f ex

clus

ive

brea

stfe

edin

g at

the

age

of 4

mon

ths

[% o

f al

l mot

hers

]


p=0.303a p=0.372a p=0.002b p=0.0004b p=0.802a p=0.0001b

A

B

Fig. 1 a Unifactorial analyses of potential determinants of breast-

feeding initiation in a nationwide sample of mothers in Germany

(n = 985); the broken line represents the mean value in the total

sample. b. Unifactorial analyses of potential determinants of exclu-

sive breastfeeding at the age of 4 months in a nationwide sample of

mothers in Germany (n = 985); the broken line represents the mean

value in the total sample; *51 subjects did not record their residence

size; a tested by chi-square; b tested by Maentel-Haenszel chi-square;

Q quartile

Eur J Nutr

123

(35.7 % of exclusively breastfeeding) and highest social

class (69.0 %) were even more pronounced. Considering

all variables in a multifactorial analysis, only the commu-

nity size (small vs. large) and the social status of the

mother significantly predicted exclusive breastfeeding

(Table 1).

Information sources in breastfeeding and non-

breastfeeding mothers

The most frequently used information sources about child

nutrition were journals, the internet, and paediatricians.

Mothers who initially breastfed their children were more

likely to use the advice from their paediatrician, midwife,

professional society booklets, or the internet (Fig. 2). In

contrast, non-breastfeeding mothers were more frequently

informed by their own mothers. Furthermore, the number

of uninformed mothers was higher among non-breast-

feeding compared with breastfeeding mothers.

Frequency and determinants of maternal DHA

supplementation

Overall, 27.8 % of our sample of mothers used DHA

supplements during pregnancy (Fig. 3a) and 16.8 % in the

postnatal period (Fig. 3b). Of those mothers who supple-

mented DHA during pregnancy, 59.5 % also used supple-

ments postpartum. Only 0.4 % of those mothers who did

not use supplements during pregnancy started using sup-

plements afterwards.

Unifactorial analyses showed that mothers who had only

one child used DHA supplements in pregnancy more often

than those who already had older children (Fig. 3a). A

similar trend was observed postpartum (Fig. 3b). During

pregnancy and postpartum, DHA supplementation was

more common in the highest social class compared with

mothers from the lowest and medium class (Fig. 3a, b).

The multifactorial analyses also revealed differences in

supplement usage during pregnancy and postpartum

according to the number of children and the social status

(Table 2). In both periods, supplement usage was more

common in mothers with high versus low fish consump-

tion. However, DHA supplementation did not differ

between breastfeeding and non-breastfeeding mothers.

Discussion

The main finding of this nationwide online survey is that

about three-fourths of mothers in Germany began to

breastfeed their infants, but 29 % of these did not achieve

the recommended minimum duration of 4 months exclu-

sive breastfeeding. Since breastfeeding seems to benefi-

cially affect short-term and long-term health of mother [16]

and child [16, 17], breastfeeding initiation and duration of

exclusive breastfeeding need to increase especially in

mothers from low social classes. Non-breastfeeding

mothers less often used professional advice on child

nutrition and were more often not informed at all sug-

gesting a lack of professional support. DHA supplemen-

tation was low in total and more common during pregnancy

than postpartum. Mothers in the highest social class used

DHA supplements more often than those in lower classes.

Since postnatal DHA supplementation did not differ

between breastfeeding and non-breastfeeding mothers,

mothers might at least partly use supplements for their own

health. The benefit was questionable since especially those

Table 1 Results of the multifactorial analyses of determinants of

breastfeeding initiation and exclusiveness at the age of 4 months

Determinant Breastfeeding

initiation

Exclusive

breastfeeding at

4 months

OR 95 % CI OR 95 % CI

Model 1

Mother’s age

Q1 versus Q4 0.841 0.539–1.314 2.449 0.433–13.842

Q2 versus Q4 1.184 0.707–1.980 0.816 0.493–1.350

Q3 versus Q4 1.368 0.849–2.204 1.150 0.718–1.842

First child

Yes versus No 1.779 1.272–2.488 0.988 0.751–1.300

Social status

Low versus high 0.372 0.244–0.569 0.272 0.191–0.387

Medium versus high 0.768 0.504–1.169 0.704 0.510–0.970

Part of Germany

North versus south 1.418 1.007–1.997 0.989 0.734–1.332

West versus east 0.563 0.348–0.909 0.852 0.599–1.210

Model 2

Mother’s age

Q1 versus Q4 0.859 0.541–1.362 2.655 0.469–15.015

Q2 versus Q4 1.022 0.604–1.731 0.845 0.503–1.419

Q3 versus Q4 1.305 0.804–2.118 1.107 0.683–1.792

First child

Yes versus no 1.828 1.292–2.585 0.944 0.712–1.252

Social status

Low versus high 0.362 0.234–0.560 0.288 0.199–0.417


Part of Germany


West versus east 0.540 0.322–0.905 0.799 0.552–1.158

Residence size

Small versus large 0.893 0.446–1.789 0.551 0.311–0.976

Medium versus large 0.795 0.538–1.176 0.631 0.460–0.866

Bold values indicate 95 % CI not overlapping the value 1

Eur J Nutr

123

mothers who already ate fish frequently also used

supplements.

Although a comparison of present findings on breast-

feeding rates with those from earlier studies in Germany is

difficult due to methodological differences, e.g., in out-

come assessments methods, our results might indicate a

slight decrease in breastfeeding initiation in Germany in

recent years, as the nationwide KiGGS study observed that

81.5 % of all infants born in 2005 were initially breastfed

[3], and the regional Bavarian Breastfeeding Study showed

initial breastfeeding rates of 89.5 % in 2005 [7]. In con-

trast, rates of 4 months exclusive breastfeeding seem to

have improved during the last 15 years from 33 %

observed nationwide in 1997/1998 [4] to 41.7 % in Bavaria

in 2005 [7] to more than 55 % in the present nationwide

study. This trend needs to continue as almost one half of

the mothers in Germany still do not exclusively breastfeed

for at least 4 months as recommended.

Compared with other European countries, German

breastfeeding rates represent mid-field. In 2002 and 2007,

information on breastfeeding in European countries was

reviewed as part of the project ‘‘Promotion of Breastfeed-

ing in Europe’’ [5, 6]. The results from 2002 suggest a wide

range of reported breastfeeding initiation with particularly

high values in Northern countries (e.g., more than 90 % in

Norway, Sweden and Iceland) and low rates of only 53 %

in France [5]. In general, rates of exclusive breastfeeding

were rapidly falling with increasing infant’s age. At

3–4 months of age, exclusive breastfeeding rates ranged

from 31 % in Poland to 79 % in Austria in 2002 [5]. The

re-evaluation in 2007 pointed to slight improvements in

breastfeeding initiation and exclusiveness across Europe

[6]. A review of international data showed higher rates of

breastfeeding initiation and duration in Europe compared

with the USA [18], but more recent data from the USA

indicated that initial breastfeeding rates had approached

our results [19]. Considering the results from Northern

European countries, there is obviously space to improve

both breastfeeding initiation and duration in Germany.

Focussing on vulnerable groups with low breastfeeding

rates is an obvious, but challenging approach of breast-

feeding promotion. Similar to previous studies in Germany

and developed countries worldwide, our analyses revealed

that the social status was an important determinant for both

breastfeeding initiation and exclusiveness. In the German

KIGGS study, the social status had the strongest impact on

rates of breastfeeding initiation [3], and in the earlier

German SuSe study, the maternal educational status (part

of the social status in the present study) was associated

with short-term breastfeeding [20]. Literature between

1990 and 2000 showed that breastfeeding initiation and

duration were positively associated with the socioeconomic

status at least in developed countries [21]. Other reviews

confirmed this positive association between education and

socioeconomic variables with breastfeeding duration [18,

22], although results were found to be not univocal [22].

Social disparities in breastfeeding might be successfully

reduced as the level of education determined rates of

breastfeeding in a feeding study in Perth, Australia, in

1992/93, but not in 2002/2003 [23].

In accordance with earlier German studies [3, 20], our

data showed regional differences in breastfeeding. Mothers

in East Germany more frequently initiated breastfeeding

than West German mothers without any resulting differ-

ences in exclusive breastfeeding at 4 months of age.

Apparently, mothers in East Germany were less successful

in establishing exclusive breastfeeding. While the present

results suggest that discontinuation rates might be higher in

small communities, others found no differences in breast-

feeding according to the community size [7]. As earlier

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

Journals Pediatrician Midwife Professionalsocieties´booklets

Foodproducers´information

Internet Mother Friends Not informed

Non-Breastfeeding

Breastfeeding

Rat

es o

f m

othe

rs [

%]

p=0.555 p=0.024 p=0.0002 p=0.237 p=0.043 p=0.009p=0.380p=0.022p=0.005

Fig. 2 Information sources on child nutrition used by breastfeeding and non-breastfeeding mothers in a nationwide sample of mothers in

Germany (n = 985); tested by chi-square test

Eur J Nutr

123

studies did not examine the impact of the community size

in Germany, its influence on breastfeeding needs to be

studied further. The same applies to potential differences in

breastfeeding rates according to maternal age. In contrast

to most international studies and an early German study

[20], we did not observe an association with age in the

multifactorial analyses. Kohlhuber et al. [7] also did not

observe an association with age in their adjusted models at

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Maternal age

Rat

es o

f D

HA

sup

plem

enta

tion

[%

of

all m

othe

rs]


p=0.339a p=0.360a p=0.135b p=0.586b p=0.015a p<0.001b

0.0

5.0

10.0

15.0

20.0

25.0

Maternal age

Rat

es o

f D

HA

sup

plem

enta

tion

[%

of

all m

othe

rs]


p=0.074a p=0.608a p=0.009b p=0.145b p=0.058a p<0.001b

B

A

Fig. 3 a Unifactorial analyses of potential determinants of DHA

supplementation during pregnancy in a nationwide sample of mothers

in Germany (n = 985). b. Unifactorial analyses of potential determi-

nants of DHA supplementation postpartum in a nationwide sample of

mothers in Germany (n = 985); *51 subjects did not record their

residence size; atested by chi-square; btested by Maentel-Haenszel

chi-square; Q quartile

Eur J Nutr

123

least in breastfeeding initiation. As breastfeeding practices

of younger and older mothers in Germany seem to have

come closer, a tailored breastfeeding monitoring is needed

to analyse whether breastfeeding is getting more popular in

younger mothers or less popular in older mothers.

Since our study showed that mothers who did not

breastfeed were less likely to be informed by their paedi-

atrician or midwife and were more often not informed at

all, active offering of professional support might be a

feasible approach for breastfeeding promotion. In Bavaria,

information on breastfeeding before birth was positively

associated with initial breastfeeding [7]. While Dennis

concluded that results from descriptive and correlational

studies on the effect of professional support are inconsis-

tent [21], and a Cochrane review of 11 randomized con-

trolled trials in low-income women in the USA showed that

health education can improve breastfeeding initiation.

Interestingly, professional support as well as lay support

proved to increase the breastfeeding duration in a recent

Cochrane review of 52 studies [24]. Intervention trials in

Germany are needed to assess the transferability of the

observed beneficial effects of breastfeeding support. The

German National Breastfeeding Committee already pro-

vides several lines of information that addresses profes-

sionals as well as parents/mothers [25]. Since present

findings indicated that the internet has become an impor-

tant information sources of infant nutrition, professional

societies should provide scientifically based, easy accessi-

ble internet information on breastfeeding in plain words

and even more practically in the form of films or video.

A DHA intake of 200 mg per day is recommended for

women during pregnancy and lactation to meet the

requirements of the offspring [26], which can be achieved

with the consumption of one to two portions of sea fish per

week [26]. In the present study, only 41 % of the mothers

reported to eat fish at least once per week. This finding is in

line with the latest nationwide German dietary survey

which revealed low mean intake levels for fish and fish

products of 13 g per day in women [13]. The usage of

DHA supplements might be an alternative approach to

achieve the recommendations in mothers with insufficient

Table 2 Results of the multifactorial analyses of determinants of

DHA supplement usage during pregnancy and postpartum

Determinant Supplements during

pregnancy

Supplements

postpartum

OR 95 % CI OR 95 % CI

Model 1

Mother’s age

Q1 versus Q4 0.924 0.608–1.402 0.751 0.459–1.231

Q2 versus Q4 1.089 0.694–1.709 0.856 0.502–1.459

Q3 versus Q4 0.964 0.633–1.468 0.849 0.520–1.385

First child

Yes versus No 1.435 1.069–1.927 1.455 1.022–2.072

Social status

Low versus high 0.563 0.387–0.820 0.548 0.353–0.852


Part of Germany


West versus east 1.129 0.768–1.658 1.477 0.909–2.400

Model 2

Mother’s age

Q1 versus Q4 0.975 0.637–1.492 0.795 0.482–1.314

Q2 versus Q4 1.184 0.748–1.874 0.890 0.516–1.534

Q3 versus Q4 0.982 0.641–1.502 0.880 0.538–1.441

First child

Yes versus No 1.369 1.013–1.851 1.385 0.966–1.984

Social status

Low versus high 0.604 0.409–0.891 0.597 0.379–0.940


Part of Germany

North versus South 0.863 0.618–1.204 0.928 0.626–1.376

West versus East 1.106 0.743–1.648 1.381 0.841–2.267

Residence size

Small versus large 0.607 0.312–1.181 0.417 0.171–1.018


Model 3

Mother’s age

Q1 versus Q4 1.039 0.674–1.601 0.871 0.522–1.453

Q2 versus Q4 1.282 0.804–2.044 0.978 0.561–1.705

Q3 versus Q4 1.032 0.671–1.589 0.930 0.562–1.538

First child

Yes versus no 1.440 1.058–1.960 1.460 1.008–2.114

Social status

Low versus high 0.605 0.406–0.902 0.632 0.396–1.011


Part of Germany


West versus east 1.174 0.783–1.760 1.560 0.941–2.588

Residence size

Small versus Large 0.685 0.349–1.345 0.495 0.200–1.228


Table 2 continued

Determinant Supplements during

pregnancy

Supplements

postpartum

OR 95 % CI OR 95 % CI

Breastfeeding

No versus Yes 1.115 0.770–1.615 0.876 0.550–1.394

Maternal fish consumption

\1 per week versus

C1 per week

0.489 0.364–0.658 0.361 0.252–0.518

Bold values indicate 95 % CI not overlapping the value 1

Eur J Nutr

123

fish intake, but in the present study, only 27 % of the study

sample used DHA supplements during pregnancy. Higher

rates in a regional survey in maternity units in Munich of

41.8 % DHA-supplementing mothers during pregnancy

[27] might reflect social differences between the study

samples, as more than 54 % of the latter study sample had

a high educational level [27]. This social homogeneity

might also explain the missing association between edu-

cation and DHA supplementation observed by Becker et al.

[27], whereas mothers from lower social classes less likely

used DHA supplements in the present study.

The provision of information during pregnancy was

observed to be positively associated with maternal sup-

plement usage in general [27]. As mothers from lower

social classes in the present study were prone for both low

rates of breastfeeding and DHA supplement use, a com-

bination of educational programs for breastfeeding pro-

motion and information on DHA supplements might be

useful. The latter should focus on mothers with insufficient

fish consumption as especially mothers with already suf-

ficient fish intake also used DHA supplements in the

present study. Not only supplements should be addressed,

but also fish as a natural DHA source as a recent ran-

domized controlled trial showed that educational inter-

ventions can effectively increase the DHA intake from fish

during pregnancy [28].

Although the present nationwide survey was weighed

according to the distribution of several sociodemographic

variables in mothers in Germany, results cannot be con-

sidered as representative per se as, e.g., mothers without

internet access were not able to participate. Another limi-

tation might be the retrospective assessment of breast-

feeding and supplement use. Although a review indicated

that maternal recall of breastfeeding initiation and duration

is valid and reliable in recall periods up to 3 years [29],

others suggest that maternal recall overestimates the

duration breastfeeding in particular [30].

Considering these limitations, our findings might overesti-

mate current rates of breastfeeding in Germany. Strengths of

our study were the sample size, the nationwide assessment, and

the weighing of our data which should increase the external

validity of our results. The retrospective assessment was less

time intensive for participants and should, therefore, increase

the response rate especially in mothers from lower social

classes. Thus, the risk of a selection bias might be reduced as

well as the risk of an overestimation of true breastfeeding and

supplementation rates.

Conclusion

Rates of breastfeeding initiation and the duration of

exclusive breastfeeding in particular need to be improved

in Germany, especially in mothers from lower social

classes. Professional counselling and support, with a focus

on mothers in high-risk groups, might be useful to increase

current rates of breastfeeding initiation and exclusiveness

and to ensure a sufficient DHA supply during pregnancy

and lactation.

Acknowledgments All authors participated in designing the survey

questionnaire and in manuscript preparation and critical revision, LL

and MS conducted the statistical analyses and data interpretation, LL

wrote the manuscript, and MK supervised the study. MK had full

access to all the data in the study and takes responsibility for the

integrity of the data and the accuracy of the data analysis. The authors

declare no conflict of interest. The PINGU project was financially

supported by the German federal ministry of education and research

(Forderkennzeichen 01EA1335). We are very grateful to Prof. Dr.

Walter Kramer, University of Dortmund, for his statistical expertise

and to Dr. Constanze Cholmakow-Bodechtel, Kantar Health GmbH,

for the organisation of the online survey.

Conflict of interest All authors have no conflict of interests.

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http://www.bfr.bund.de/de/informationen_zum_stillen_fuer_fachpersonal_und_muetter_eltern-10207.html

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