Using Conceptual Models to Tackle Complex Public Health Problems Affecting MCH Populations

An Example of How Structural and Intermediary Determinants of Health Affect Breastfeeding Rates among African American Women

Despite the many known benefits of breastfeeding, a persistent discrepancy exists between African American mothers and mothers of other races who breastfeed. According to the Centers for Disease Control and Prevention (CDC), among all children born during 2010–2013, 64.3 percent of African American women initiated breastfeeding, compared to 81.5 percent for Whites, and 81.9 percent for Hispanics. The percentage point difference in the rate of exclusive breastfeeding through 6 months and breastfeeding at 12 months between African American and White infants was 8.5 and 13.7, respectively. Multiple factors influence a woman’s decision to start and continue breastfeeding. However, certain barriers are disproportionately experienced by African American women.

Using the Word Health Organization’s (WHO) Conceptual Framework for Action on the Social Determinants of Health, I attempt to show you in a simplified manner how structural and social determinants of health shape these lower breastfeeding (BF) rates (i.e., initiation, exclusivity up to 6 months, and duration up to 12 months) among African American women. Following the proposed conceptual model, I briefly explain each construct and how they interact to shape BF rates among African American women.

Structural determinants of low BF rates among African American women include (1) the U.S. Federal Employment and Labor Laws (e.g., Family and Medical Leave Act -FMLA), (2) social norms (e.g., embarrassment/ fearful of being stigmatized when they breastfeed in public, sexualizing women’s breasts as objects of male desire, the cultural belief that the use of cereal in a bottle will prolong the infant’s sleep), (3) discrimination, racism, and harassment (e.g., race, religion, appearance), and (4) sexual division of power and labor (e.g., sexual division of labor reduces women’s economic status by distributing wealth in ways that disadvantage caregiving relative to specific forms of productive work, role differentiation leads to unequal parental role expectations and economic opportunity). These structural determinants affect not only occupation and income, but also the following intermediary determinants: (1) material circumstances (e.g., earlier return to work, unsupportive work and childcare environments), (2) psychosocial factors (e.g., poor partner, family and social support, commercial pressures to not breastfeed or stop BF via aggressive marketing campaigns of formula producers), and (3) healthcare system (e.g., inadequate delivery of BF information by providers, lack of access to professional BF support, provision of supplemental feeding to healthy full-term breastfed babies during the postpartum stay, separation of mothers from babies during their hospital stay). Together, these social determinants of health inequities and health shape BF rates in African American women.

Using the WHO’s Framework for Action on the Social Determinants of Health, can you think about any other public health problem that affects MCH populations?

References:

Anstey EH, Chen J, Elam-Evans LD, Perrine CG. Racial and Geographic Differences in Breastfeeding — United States, 2011–2015. MMWR Morb Mortal Wkly Rep. 2017;66(27):723-727. doi:10.15585/mmwr.mm6627a3

Solar O, Irwin AA. A Conceptual Framework for Action on the Social Determinants of Health: Determ Heal Discuss (Policy Pract. 2010:1-79. doi:ISBN 978 92 4 150085 2