“The world’s highest reported rates of Fetal Alcohol Spectrum Disorder (FASD) are found in South Africa” 1.
This was what I came across when I was conducting a literature review for my work. In my work, we focus on the prenatal alcohol and/or drug exposure in the Finnish population, but inspired by the literature, I wanted to look at the topic in a different, yet interesting context, South Africa. Why is the prevalence of FASD in this country highest in the world, and are there any preventive strategies available to tackle the problem?
The term Fetal Alcohol Spectrum Disorder (FASD) is used to describe a broad spectrum of disabilities that result from prenatal alcohol exposure 2. It is viewed as an umbrella term to encompass other diagnostic categories including fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS) 2, alcohol-related birth defects (ARBD) and alcohol-related neurodevelopmental disorder (ARND) 8.
Alcohol consumption during pregnancy negatively affects fetal development. The most profound effects of prenatal alcohol exposure are on the developing brain, others are cognitive and behavioral effects 3, birth defects, craniofacial anomalies, growth retardation and central nervous system dysfunction 4. Studies have recognized that the disabilities associated with FASD are lifelong and many of the physical, brain and neurodevelopmental features persist into adulthood 4. Secondary disabilities, including school dropouts, trouble with the law and substance/alcohol abuse problems, are common in young adults with FASDs 4. In addition, studies show that people with FASD are more likely to be unemployed, receive special education, have more mental health problems, and/or attention difficulties like attention deficit hyperactivity disorder (ADHD) 4, 9, 15.
The total alcohol consumption per capita in South Africa is nearly twice as high as the average of World Health Organization (WHO) African region (11 liters of pure alcohol per capita vs. 6 liters of pure alcohol per capita, respectively) 14. Also, heavy episodic maternal drinking is common in South Africa, and the consequences of prenatal alcohol exposure represent a major public health issue 7. A safe level of alcohol consumption during pregnancy has not been established 12, 15, and alcohol consumed even at low levels can permanently damage the fetal brain 16. Higher amounts and longer duration of prenatal alcohol exposure increases the risk of central nervous dysfunction of a fetus 17. Estimates show that the prevalence of FASD in South Africa is 29-290 per 1000 live births 10 or 111,1 per 1000 population as Chudley estimates 11. Even with the broad estimates, the prevalence of FASD is significantly higher compared to the global estimates (7.7/1000 population) 19. The prevalence of FAS, which is the extreme end of the spectrum is also high in the region (40,5-46,4/1000 10 or 585,3/10 000 people 18) compared to estimates for developed world (0,97/1000) 10 or compared to countries where the prevalence of FAS is also high, like Croatia (115,2/10 000) 18.
To understand the reasons behind the heavy alcohol consumption, maternal drinking, and the high rates of FASD in South Africa, there is a need to understand the historical, cultural and political roots of alcohol in the region. During the colonial era, a regular allowance of wine was given to workers on the wine farms. After emancipation in the 1830s, this evolved into the so-called ‘dop’ system, whereby weekly wages were supplemented with alcohol 5. This system was used in the farms until the late 1990s 5. The ‘dop’ system may partly explain the risky drinking practices, especially in specific areas in South Africa 5. However, there has been a criticism against the assumption 6.
Another suggested explanation is that heavy, episodic drinking has been a norm for generations: it is a common form of recreation and socially accepted in South Africa, also among pregnant women 6. The increase in the supply of commercially available alcohol and social liberation 7, as well as the increased alcohol availability and the role of alcohol industry in the region 20, can also partly explain the risky alcohol consumption in the region 7. Other than that, the norms and practices of binge drinking (with no reduction during pregnancy), deprived living conditions and low socioeconomic status, insufficient nutrition, high fertility rate, and challenging conditions for prenatal and postnatal development should also be considered as risk factors for maternal alcohol consumption 10.
Effective actions to prevent prenatal alcohol exposure exist. FASD is an under-diagnosed neurodevelopmental disability in South Africa and surveillance systems with data collection tools are needed 13. Throughout Africa, there is a gap in policy and service implementation, which impairs the translation of knowledge into effective prevention and intervention strategies 1. Policies addressing the problem nationwide are urgently needed 13 and the high prevalence of FASD should be acknowledged as a public health priority 10. Public health education and awareness raising regarding alcohol consumption during pregnancy and FASD are needed in the region, especially in the rural areas were more FAS exist 7. In addition, there is a need to identify the risk factors for maternal alcohol consumption as mentioned above.
Healthcare professionals should be trained to screen for, diagnose, prevent, and treat an alcohol-exposed pregnancy 13, and alcohol use could be integrated into the prenatal screening, as is done with HIV and Tuberculosis, for instance 7. Finally, as teenage and unplanned pregnancies are common in South Africa, the topic should be brought up at an earlier age 13.
Sustainable actions to tackle the problem in South Africa are urgently needed. To reduce the high prevalence of FASD in the region, there is a need to reduce the risky alcohol consumption in general. Finally, alcohol-related harms and the role of the alcohol industry should receive more attention, also on a political level 20.
Niina-Maria Nissinen is a young public health professional from Finland and the news coordinator at GHNGN. She currently works as a research coordinator in Finland, and her work focuses on prenatal alcohol/drug exposure.
- Colleen, M.A. (2017). Fetal Alcohol Spectrum Disorder in Africa. Current Opinion in Psychiatry, 30(2), pp. 108-112.
- Reid, N., Shelton, D., Warner, J., O’Callaghan, F. & Dawe, S. (2017). Profile of children diagnosed with a fetal alcohol spectrum disorder: A retrospective chart review. Drug and Alcohol Review, no. 36, pp. 677-681.
- Riley, E.P., Infante, A. & Warren, K.R. (2011). Fetal Alcohol Spectrum Disorder: An Overview. Neuropsychology Review, no. 21, pp. 73-80.
- Moore, E.M. & Riley, E.P. (2015). What Happens When Children with Fetal Alcohol Spectrum Disorders Become Adults? Current Developmental Disorders Reports, no, 2, pp. 219-227.
- Urban, M.F., Olivier, L., Louwbm, J.G., Lombardb, C., Viljoen, D.L., Scorgie, F. & Chersichd, M.F. (2016). Changes in drinking patterns during and after pregnancy among mothers of children with fetal alcohol syndrome: A Study in three districts of South Africa. Drug and Alcohol Dependence, no. 168, pp. 13-21.
- May, P.A., Gossage, J.P., Brooke, L.E., Snell, C.L., Marais, A-S., Hendricks, L.S., Croxford, J.A. & Viljoen, D.L. (2005). Maternal Risk Factors for Fetal Alcohol Syndrome in the Western Cape Province of South Africa: A Population-Based Study. American Journal of Public Health, 95(7), pp. 1190-1199.
- Viljoen, D.L, Gossage, J.P., Brooke, L., Adnams, C.M., Jones, K.L., Robinson, L.K., Hoyme, H.E., Snell, C., Khaole, N.C.O., Kodituwakku, P., Asante, K.O., Findlay, R., Quinton, B., Marais, A-S., Kalberg, W.O. & May, P.A. (2005). Fetal alcohol syndrome epidemiology in a South African community: a second study of a very high prevalence area. Journal of Studies on Alcohol, 66(5), pp. 596-604.
- Hoyme, H.E., May, P.A., Kalber, W.O., et al. (2005). A practical clinical approach to the diagnosis of fetal alcohol spectrum disorders; clarification of the 1996 institute of medicine criteria. Pediatrics, 115(1), pp. 39-47.
- Rangmar, J., Hjern, A., Vinnerljung, B., Strömland, K., Aronson, M. & Fahlke, C. (2011). Psychosocial Outcomes of Fetal Alcohol Syndrome in Adulthood. Pediatrics, 135(1), pp. 52-58.
- Olivier, L., Curfs, L.M., & Viljoen, D.L. (2016). Fetal alcohol spectrum disorders: Prevalence rates in South Africa. South African Medical Journal, 25(106), pp. 103-106.
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- May, P.A. & Gossage, J.P. (2011). Maternal risk factors for fetal alcohol spectrum disorders, not as simple as it might seem. Alcohol Research and Health, 34(1), pp. 15-26.
- Rosenthal, J., Christianson, A. & Cordero, J. (2005). Fetal Alcohol Syndrome Prevention in South Africa and Other Low-Resource Countries. American Journal of Public Health, 95(7), pp. 1099-1101.
- World Health Organization (WHO) (2014). South Africa: Alcohol Consumption: Levels and Patterns. Available at: <http://www.who.int/substance_abuse/publications/global_alcohol_report/profiles/zaf.pdf> [Accessed 23 January 2018].
- Clarke, M.E. & Gibbard, W.B. (2003). Overview of Fetal Alcohol Spectrum Disorders for Mental Health Professionals. The Canadian Child and Adolescent Psychiatry Review, 12(3), pp. 57-63.
- Hepper, P.G., Dornan, J.C. & Little, J.F. (2005). Maternal alcohol consumption may delay the development of spontaneous fetal startle behavior. Physiology & Behavior, 83(5), pp. 711-714.
- Streissguth, A.P. (1994). A long-term perspective of FAS. Alcohol Health & Research World, 18(1), pp. 74-82.
- Popova, S., Lange, S., Probst, C., Gmel, G. & Rehm, J. (2017). Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. The Lancet Global Health, 5(3), pp. e290-e299.
- Lange, S., Probst, S. & Gmel, G. (2017). Global Prevalence of Fetal Alcohol Spectrum Disorder Among Children and Youth. A Systematic Review and Meta-analysis. JAMA Pediatrics, 171(10), pp. 948-956.
- Ferreira-Borges, C., Parry, C.D.H. & Babor, T.F. (2017). Harmful Use of Alcohol: A Shadow over Sub-Saharan Africa in Need of Workable Solutions. International Journal of Environmental Research and Public Health, 14(4), 346.